February 19-22, 2015Monterey Marriott Monterey, California

Jointly Sponsored by the American College of Surgeons and the Pacific Coast Surgical Assocation.

Pacific Coast Surgical Association

86th ANNUAL MEEtING

scIENtIfIc proGrAM

- 1 -

Pacific Coast Surgical Association86th Annual Meeting

ScientiFic ProgramFebruary 19-22, 2015

Monterey MarriottMonterey, California

table of contents2015 Arrangements / Program Committee............................Page 2 Council Officers, Members, and Representatives.................Page 3 General Agenda........................................................................Page 4Scientific Program Information................................................Page 6Disclosure Information.............................................................Page 7Scientific Program...................................................................Page 12Scientific Session Agenda......................................................Page 14Scientific Sessions 1-27..........................................................Page 24E-Poster Sessions A.................................................................Page 69E-Poster Sessions B.................................................................Page 87E-Poster Sessions C...............................................................Page 104Founders................................................................................Page 122Past Presidents.......................................................................Page 123New Members.......................................................................Page 126In Memoriam.........................................................................Page 134Future Meetings....................................................................Page 147

- 2 -

President and Spouse William and Gisela SchecterVice-President Douglas Grey

Recorder Jonathan HiattRecorder-Elect Christian de Virgilio

Golf Tournament Steve EtheredgeTennis Tournament Jerry Sydorak

Fun Run/Walk Ed KimArrival/Hospitality Steve Stanten

Spouse Activities Jim MachoChildren/Family Activities Wen Shen

President’s Reception and Dinner Diana FarmerSpousal Hospitality Carolyn Grey and Gisela Schecter

Program Chair and Recorder (2015) Jonathan HiattRecorder-Elect Christian deVirgilio (2015)

Members: William Schecter (2015)Quan-Yang Duh (2016)J. David Beatty (2015)James Dolan (2018)L. Andrew DiFronzo (2015)Gregory Victorino (2017)

2015 Arrangements Committee

2015 Program Committee

- 3 -

Council Officers

Council Members

Council Representatives

William Schecter, President (2015) San Francisco, CADouglas Grey, Vice-President (2015) San Francisco, CA

John A. Ryan, Jr., Historian Seattle, WAQuan-Yang Duh, Secretary-Treasurer (2016) San Francisco, CA

Jonathan R. Hiatt, Recorder (2015) Los Angeles, CAChristian de Virgilio, Recorder-Elect (2015) Los Angeles, CA

President President-Elect Vice-President

HistorianSecretary-Treasurer

Recorder

Richard Bold, Councilor (2018) Northern CaliforniaKaren E. Deveney, Councilor (2015) Oregon/Hawaii

Edward Phillips, Councilor (2017) Southern CaliforniaRobert Sawin, Councilor (2016) Washington/British Columbia/Alaska

Armando Giuliano, Los Angeles, CA (10/2016)

Board of Governors, American College of Surgeons

John G. Hunter, Portland, OR (6/30/2016) American Board of SurgerySherry Wren, Stanford, CA (12/31/2016) Advisory Council for General Surgery,

American College of Surgeons

- 4 -

general agendaWEDnESDAY, FEBRuARY 18

Council Reception* 6:00 pm – 7:00 pm 1833 RestaurantCouncil Dinner* 7:00 pm – 9:00 pm 1833 Restaurant

THuRSDAY, FEBRuARY 19Finance Committee Meeting* 7:00 am – 8:00 am Santa Barbara RoomCouncil Meeting* 8:30 am – 3:00 pm Santa Barbara RoomCouncil Photo* 12:00 pm – 12:15 pm TBDCouncil and Industry Support Lunch* 12:15 pm – 1:15 pm Los Angeles RoomRegistration 1:00 pm – 6:00 pm San Carlos FoyerGuest Hospitality Room 1:00 pm – 5:00 pm Salon 209Hospitality Desk 1:00 pm – 5:00 pm San Carlos FoyerSpeaker Ready Room 3:00 pm – 6:00 pm San Francisco RoomNew Members Private Reception* 5:00 pm – 6:00 pm Presidential SuiteWelcome Reception 6:00 pm – 7:45 pm Ferrantes Bay View

FRiDAY, FEBRuARY 20Continental Breakfast 7:00 am – 9:00 am San Carlos I & IIRegistration 7:00 am – 5:00 pm San Carlos FoyerSpeaker Ready Room 7:00 am – 5:00 pm San Francisco RoomGuest Hospitality Room 7:00 am– 5:00 pm Salon 209Industry Support Exhibits 7:00 am – 4:00 pm San Carlos I & IIHospitality Desk 8:00 am – 12:00 pm San Carlos FoyerIntroduction and President’s Address 8:00 am – 9:00 am San Carlos III & IVScientific Session I 9:00 am – 10:15 am San Carlos III & IVMorning Break with Industry Support

10:15 am – 10:40 am San Carlos I & II

Scientific Session II 10:40 am – 12:20 pm San Carlos III & IVLunch/E-Poster Sessions 12:20 pm – 2:00 pm Los Angeles, Santa

Barbara, Santa Monica

Walking Tour of Carmel 12:30 pm – 4:00 pm Meet in Lobby by 12:20 pmScientific Session III 2:00 pm – 3:15 pm San Carlos III & IV

- 5 -

Afternoon Break with Industry Support

3:15 pm – 3:40 pm San Carlos I & II

Scientific Session IV 3:40 pm – 4:55 pm San Carlos III & IV Party with Blues Band 5:00 pm – 7:00 pm Ferrantes Bay ViewDinner at Leisure 7:00 pm

SATuRDAY, FEBRuARY 21Continental Breakfast 7:00 am – 9:00 am San Carlos I & IIIndustry Support Displays 7:00 am – 11:30 am San Carlos I & IIGuest Hospitality Room 7:00 am – 12:00 pm Salon 209Speaker Ready Room 7:00 am – 12:00 pm San Francisco RoomRegistration 7:30 am – 12:00 pm San Carlos FoyerScientific Session V 7:45 am – 9:50 am San Carlos III & IVHospitality Desk 8:00 am – 12:00 pm San Carlos FoyerMorning Break with Industry Support 9:50 am – 10:15 am San Carlos I & IIHistorical Vignette 10:15 am – 10:45 am San Carlos III & IVPresident’s Forum 10:45 am – 12:15 pm San Carlos III & IVGolf Tournament 12:45 pm – 5:30 pm Del Monte Golf CourseFun Run & Walk 1:30 pm – 2:30 pm Meet in Lobby by 1:20 pmTennis Tournament 1:30 pm – 4:00 pm Meet in Lobby by 12:55 pmPresidents’ Reception 6:30 pm – 7:15 pm San Carlos FoyerPresidents’ Dinner 7:15 pm – 10:00 pm San Carlos Ballroom

SunDAY, FEBRuARY 22Continental Breakfast 7:00 am – 9:00 am San Carlos I & IIRegistration 7:00 am – 12:00 pm San Carlos FoyerSpeaker Ready Room 7:00 am – 12:00 pm San Francisco RoomGuest Hospitality Room 7:00 am – 10:30 am Salon 209Scientific Session VI 7:45 am – 9:50 am San Carlos III & IVScientific Session VII 9:50 am – 11:30 am San Carlos III & IVBusiness Meeting 11:30 am – 12:00 pm San Carlos III & IVMeeting Adjourns by 12:00 pm*Invitation only events

- 6 -

Scientific Program InformationOverall Goal and Objectives of the Program: The goal of the program is to provide an educational opportunity for the members of PCSA. Members are academic and community surgeons from four caucuses – Northern California, Southern California, Washington/British Columbia/Alaska, and Hawaii/Oregon. Membership is competitive. Attendees represent the leaders of their medical communities.

Learning Outcomes: The meeting will provide high quality up-to-date information regarding major areas in general surgery. Attendees will learn the most recent developments in the field of surgery from scientific and clinical leaders. Time will be provided following each presentation for questions and discussion. Moderators will oversee sessions and facilitate discussions.

Accreditation Statement: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American College of Surgeons and the Pacific Coast Surgical Association. The American College of Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

AMA PRA Category 1 Credits™: The American College of Surgeons designates this live activity for a maximum of 15.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure: In compliance with the ACCME Accreditation Criteria, the American College of Surgeons must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. All reported conflicts are managed by a designated official to ensure a bias-free presentation. Please see the insert to this program for the complete disclosure list.

Disclaimer: Attendees voluntarily assume all risks involved in travel to and from the Annual Meeting and in attendance of and participation in the program. PCSA and ACS Association Management Services shall not be liable for any loss, injury, or damage to person or property resulting directly or indirectly from any acts of God, acts of government or other authorities, civil disturbances, acts of terrorism, riots, thefts, or from any other similar causes.

Division of Education

- 7 -

american coLLege oF SurgeonS | DiViSion oF eDucationJoint SPonSorSHiP Program

Disclosure InformationPcSa’s 86th annual meeting

February 19-22, 2015 monterey, california

In accordance with the ACCME Accreditation Criteria, the American College of Surgeons, as the accredited provider of this activity, must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. Therefore, it is mandatory that both the program planning committee and speakers complete disclosure forms. Members of the program committee were required to disclose all financial relationships and speakers were required to disclose any financial relationship as it pertains to the content of the presentations. The ACCME defines a ‘commercial interest’ as “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients”. It does not consider providers of clinical service directly to patients to be commercial interests. The ACCME considers “relevant” financial relationships as financial transactions (in any amount) that may create a conflict of interest and occur within the 12 months preceding the time that the individual is being asked to assume a role controlling content of the educational activity. ACS is also required, through our joint sponsorship partners, to manage any reported conflict and eliminate the potential for bias during the activity. All program committee members and speakers were contacted and the conflicts listed below have been managed to our satisfaction. However, if you perceive a bias during a session, please report the circumstances on the session evaluation form. Please note we have advised the speakers that it is their responsibility to disclose at the start of their presentation if they will be describing the use of a device, product, or drug that is not FDa approved or the off-label use of an approved device, product, or drug or unapproved usage. The requirement for disclosure is not intended to imply any impropriety of such relationships, but simply to identify such relationships through full disclosure and to allow the audience to form its own judgments regarding the presentation.

- 8 -

spEAKErs / MoDErAtors/ chAIrs / DIscUssANts

NothING to

DIscLosE

DIscLosUrE(As it pertains to the content of the

presentation)podium and E-poster presenters

Ariana Afshar xEvan Alicuben x

Galinos Barmparas xElizabeth Benjamin x

Breanne Britton xNathan Bronson x

Erin Brown xRachael Callcut xEric Campion xDavid Chang xAudrey Choi x

Vincent Chong xAlice Chung x

Christopher Connelly xMackenzie Cook xJeffrey Crawford x

David Daar xElizabeth David x

Aaron Dawes xHaile Debas x

J. Salvador De La Cruz xJoseph DiNorcia x

Aimee Gough xAmanda Graff-Baker x

Mark Hanna xDavid Hoang xJenny Hong x

Jennifer Kaplan xDavid Kaufman xKatherine Kelley x

Dennis Kim xJerry Kim xCindy Kin x

- 9 -

spEAKErs / MoDErAtors/ chAIrs / DIscUssANts

NothING to

DIscLosE

DIscLosUrE(As it pertains to the content of

the presentation)Eric Kubat x

Gregory Landry xCara Liebert x

Ning Lu xErik McDonald xEllen Morrow xDaniel Nelson xBrian Parrett x

Jennifer Pasko xJesse Pasternak x

David Pham xThomas Pham xAhmed Rahim x

Morgan Richards xSamuel Schecter x

Gail Tominaga xWilliam Toppen xJennifer Tseng x

Brant Ullery xJoseph Weber x

Anna Weiss xWeldon Williamson x

Jakub Woloszyn xGeena Wu xHuan Yan x

Christopher Yi xNoah Yuen x

DiscussantsGlenn Ault x

Peyman Benharash xStephen Bickler xRonald Busuttil x

Kristine Calhoun xWaldo Concepcion

- 10 -

Christian de Virgilio xKaren Deveney x

Arvin Gee xPhilip Haigh x

James Holcroft xClifford Ko xJason Lee x

Daniel Margulies xCol. Matthew Martin x

Lea Matsuoka xMarc Melcher xJeffrey Norton xSusan Orloff xSusan Rowell xRobert Sawin x

Martin Schreiber xShawn Steen x

Vassiliki Tsikitis xAmanda Wheeler x

Linda Wong Honoraria as Speaker for Bayer Healthcare

Karen Woo x

closersFarin Amersi x

Peyman Benharash xRichard Bold x

Andrew Bonham xRonald Busuttil x

H. Gill Cryer xHaile Debas x

Karen Deveney xJames Dolan x

Quan-Yang Duh xDavid Imagawa xGregory Landry x

Jason Lee xDaniel Margulies x

- 11 -

Lea Matsuoka xRichard Perez xAlessio Pigazzi x

William Schecter xMaheswari Senthil x

Scott Steele xPierre Theodore xDavid Thoman x

Gregory Victorino xJennifer Watters x

Linda Wong x

ModeratorsFarin Amersi x

J. David Beatty xChristian de Virgilio x

Karen Deveney xJuan Carlos Jimenez x

Jason Lee xJorge Reyes x

Vincent Rowe xSteven Stain xAreti Tillou x

Gail Tominaga xLinda Wong xSherry Wren x

pLANNING coMMIttEENothING

to DIscLosE

DIscLosUrE(All commercial relationships)

J. David Beatty xChristian de Virgilio xAndrew DiFronzo x

James Dolan xQuan-Yang Duh xJonathan R. Hiatt x

William P. Schecter xGregory Victorino x

- 12 -

Scientific Programe-PoSter SeSSionSFriday, February 20 12:20 pm – 2:00 pmE-Posters will be presented in three groups on Friday, February 20 during the lunch hour. Each 3-minute oral presentation of the E-Poster will be followed by brief questions and discussion. Box lunch will be provided.

PreSiDent’S Forum and toWn HaLLSaturday, February 21 10:45 am – 12:15 pmThe 2015 President’s Forum is entitled “Healthcare through the Lens of Poverty.” Drs. Edward E. Cornwell, III, Paul B. Hofmann, and David Hoyt will discuss the profound impact of poverty on health care utilization and how policy makers have conflated poverty with waste and inefficiency, leading to policies that seek to change clinical practices rather than approaches that could improve the care of the poor. Following the President’s Keynote Speakers, President Schecter will lead a PCSA Town Hall Panel Discussion with the audience on the Affordable Care Act, Healthcare Policies and Disparities in Access to Surgical Care.

PcSa reSiDent’S comPetitionThe top-scoring resident papers from each caucus will be presented during the scientific sessions. Presentations will be judged on clarity, focus and scientific relevance to surgical practice. Prizes will be awarded at the President’s Dinner. This year’s resident contestants are:

aimee e. gougH Southern California Friday, February 20, 9:00 am – 9:25 am“PERIPROSTHETIC ANESTHETIC FOR POSTOPERATIVE PAIN AFTER LAPAROSCOPIC VENTRAL HERNIA REPAIR: A RANDOMIzED, PLACEBO CONTROLLED TRIAL”

JeFFrey D. craWForD Oregon/Hawaii Friday, February 20, 10:40 am – 11:05 am“NATURAL HISTORY OF INDETERMINATE BLUNT CEREBROVASCULAR INJURY”

- 13 -

DanieL W. neLSon Washington/British Friday, February 20, 2:00 pm – 2:25 pm Columbia/Alaska“THROMBOEMBOLIC COMPLICATIONS FOLLOWING COLORECTAL SURGERY: ARE WE OVER-PROPHYLAXING?”

Jakub WoLoSzyn Northern California Saturday, February 21, 7:45 am – 8:05 am“IMPORTED KIDNEY GRAFTS FROM NON-CONVENTIONAL ADULT DECEASED DONORS SUCCESSFULLY INCREASE ACCESS TO TRANSPLANTATION FOR ELDERLY PATIENTS”

PcSa New Member PrizePeyman benHaraSHSouthern California Friday, February 20, 3:40 pm - 4:55 pm“SHOULD STATINS BE ADDED TO β -BLOCKERS AS A QUALITY METRIC FOR HIGH-RISK SURGICAL PATIENTS? BEYOND SCIP”

industry Support DisplaysA commercial display of scientific interest will be available during the Annual Meeting, providing an opportunity for attendees to view products and services from various vendors. Continental breakfasts and refreshment breaks will be served in the exhibit area.

PCSA would like to thank the following exhibiting companies: • AnaLogic Ultrasound (BK Medical)• Endologix • Genomic Health • Gore and Associates• Hitachi Aloka Medical• The JAMA Network• Janssen Pharmaceuticals • Strategic Business Holdings

- 14 -

Scientific Session AgendaFriDay, February 20, 20158:00 am – 8:15 am Introduction8:15 am – 8:45 am President’s Address8:45 am – 9:00 am Introduction of New Members9:00 am – 10:15 am Scientific Session 1 Moderator Sherry Wren

1 PERIPROSTHETIC ANESTHETIC FOR POSTOPERATIVE PAIN AFTER LAPAROSCOPIC VENTRAL HERNIA REPAIR: A RANDOMIzED, PLACEBO CONTROLLED TRIAL *RESIDENT PRIZE (Southern California Caucus) Presenter: Aimee Gough Discussant: Susan Rowell Closer: David Thoman

2 ROBOTIC-ASSISTED COLORECTAL SURGERY IN THE UNITED STATES: AN UPDATED ANALYSIS OF NATIONWIDE TRENDS AND OUTCOMES Presenter: Mark Hanna Discussant: Vassiliki Tsikitis Closer: Alessio Pigazzi

3 COST-EFFECTIVENESS ANALYSIS OF INGUINAL HERNIA REPAIR IN UNDOCUMENTED IMMIGRANTS Presenter: Ariana Afshar Discussant: Arvin Gee Closer: William Schecter

10:15 am – 10:40 am Morning Break with Industry Support10:40 am – 12:20 pm Scientific Session 2 Moderator Gail Tominaga

4 NATURAL HISTORY OF INDETERMINATE BLUNT CEREBROVASCULAR INJURY *RESIDENT PRIZE (Oregon/Hawaii Caucus) Presenter: Jeffrey Crawford Discussant: Karen Woo Closer: Gregory Landry

- 15 -

5 INTER-HOSPITAL VARIATION IN MORTALITY FOR PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY: DOES COMPLIANCE WITH EVIDENCE-BASED  GUIDELINES MATTER? Presenter: Aaron Dawes Discussant: Martin Schreiber Closer: H. Gill Cryer

6 EMERGENCY ABDOMINAL SURGERY IN THE CRITICALLY- ILL: WHEN IS IT FUTILE? Presenter: Ning Lu Discussant: Daniel Margulies Closer: Linda Wong

7 ALL AIR IN THE MEDIASTINUM IS NOT EQUAL: CT FINDINGS AND MORTALITY IN PATIENTS WITH PNEUMOMEDIASTINUM FROM BLUNT TRAUMA Presenter: Vincent Chong Discussant: Christian de Virgilio Closer: Gregory Victorino

12:20 pm – 2:00 pm Lunch E-Poster Sessions (A, B, C)Poster Session A: Moderators Farin Amersi and David Beatty

1a PERI-AREOLAR OR PERI-TUMORAL INJECTION OF ISOSULFAN BLUE AND THE EFFECT ON THE NUMBER OF SENTINEL LYMPH NODES EXAMINED IN BREAST CANCER Presenter: Joseph Weber

2a OMISSION OF SENTINEL NODE BIOPSY IN OLDER PATIENTS WITH EARLY STAGE INVASIVE BREAST CANCER Presenter: Alice Chung

3a INCREASING THE NUMBER OF NEGATIVE LYMPH NODES EXAMINED IN EARLY- STAGE BREAST CANCER PATIENTS WITH N1 DISEASE CORRELATES WITH IMPROVED SURVIVAL: ARE WE ADOPTING z11 TOO SOON? Presenter: Huan Yan

- 16 -

4a THE UTILITY OF BREAST SPECIFIC GAMMA IMAGING FOR INVASIVE LOBULAR CARCINOMA Presenter: Katherine Kelley

5a LONG-TERM OUTCOMES OF SCALP MELANOMA TREATED WITH EXCISION AND SENTINEL LYMPH NODE DISSECTION Presenter: Brian Parrett

6a EXTERNAL ILIAC SENTINEL NODES IN LOWER EXTREMITY MELANOMA ARE FREQUENT BUT RARELY IMPACT STAGING Presenter: Jennifer Tseng

7a UP-REGULATION OF CTLA-4 AND PD-1 GENE EXPRESSION IN SENTINEL NODES IS PREDICTIVE OF LYMPH NODE METASTASIS IN MELANOMA Presenter: David Kaufman

8a AGE-DEPENDENT EFFECTS OF RADIOTHERAPY IN PATIENTS WITH SOFT TISSUE SARCOMA UNDERGOING SURGERY Presenter: Noah Yuen

9a LONG TERM QUALITY OF LIFE FOLLOWING LAPAROSCOPIC BILATERAL ADRENALECTOMY FOR REFRACTORY CUSHING DISEASE Presenter: David Pham

10a LAPAROSCOPIC ANTRECTOMY AND OUTCOMES OF MULTIFOCAL GASTRIC CARCINOIDS WITH DIFFUSE NEURODENDOCRINE CELL HYPERPLASIA Presenter: Jenny Hong

11a SURGERY IN HIGH VOLUME HOSPITALS NOT COMMITTEE ON CANCER ACCREDITATION LEADS TO LONG-TERM CANCER SPECIFIC SURVIVAL FOR EARLY STAGE LUNG CANCER Presenter: Elizabeth David

12a THE SURVIVAL BENEFIT OF MEDIASTINAL LYMPH NODE DISSECTION FOR LUNG CANCER Presenter: Geena Wu

- 17 -

Poster Session B: Moderators Areti Tillou and Christian de Virgilio

1b 30-DAY OUTCOMES OF ELECTIVE AND EMERGENT PARAESOPHAGEAL HERNIA REPAIR: ANALYSIS OF 10,656 PATIENTS REPORTED IN THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM Presenter: Jennifer Kaplan

2b HYPONATREMIA IS ASSOCIATED WITH COMPLICATED APPENDICITIS Presenter: Dennis Kim

3b ANASTOMOTIC LEAK AFTER COLECTOMY: CURRENT RISK FACTORS, NATIONWIDE TRENDS IN MANAGEMENT AND OUTCOMES Presenter: Mark Hanna

4b ROBOTIC NOT LAPAROSCOPIC SURGERY ENABLED MINIMALLY INVASIVE TREATMENT OF RECTAL CANCER IN A VA MEDICAL CENTER Presenter: Eric Kubat

5b FACTORS ASSOCIATED WITH 30-DAY UNPLANNED SURGICAL READMISSION IN A CHILDREN’S HOSPITAL Presenter: Morgan Richards

6b CLINICAL COURSE AND RISK FACTORS FOR BILIARY COMPLICATIONS IN LIVER TRANSPLANT RECIPIENTS OF DONATION AFTER CARDIAC DEATH DONORS Presenter: Erik McDonald

7b THE IMPACT OF A POSITIVE DONOR MANAGEMENT GOAL BUNDLE STATUS CHANGE ON THE NUMBER OF ORGANS TRANSPLANTED PER DONOR AFTER NEUROLOGIC DETERMINATION OF DEATH Presenter: J. Salvador De La Cruz

8b GIANT HEMANGIOMAS- A 13-YEAR REVIEW AND THE NOVEL USE OF BLAND PRE-OPERATIVE EMBOLIzATION Presenter: Jennifer Pasko

- 18 -

9b THE CHANGING ROLE OF EXTRAANATOMIC BYPASS IN CONTEMPORARY VASCULAR SURGERY PRACTICE Presenter: Gregory Landry

10b LONG-TERM SURVIVAL AND FUNCTIONAL RESULTS FOLLOWING CAROTID ENDARTERECTOMY OR STENTING; ABSENCE OF SURVIVAL EFFECT DUE TO PREOPERATIVE SYMPTOMATOLOGY Presenter: Weldon Williamson

11b MATURATION RATES OF ONE-STAGE VERSUS TWO- STAGE BASILIC VEIN TRANSPOSITIONS Presenter: Christopher Yi

Poster Session C: Moderators Linda Wong and Juan Carlos Jimenez

1c EPISODES OF HYPOTENSION ADVERSELY AFFECT SEPSIS-INDUCED CARDIAC DYSFUNCTION IN SEPTIC SHOCK Presenter: Samuel Schecter

2c WEIGHT A MINUTE: OBESITY NO LONGER PREDICTS DEATH FOLLOWING TRAUMA? Presenter: Rachael Callcut

3c FAILURE TO RESCUE IN THE ELDERLY: A SUPERIOR QUALITY METRIC FOR TRAUMA CENTERS Presenter: Galinos Barmparas

4c NEGATIVE ABDOMINAL CT FOR TRAUMA: NOW WHAT? Presenter: Elizabeth Benjamin

5c DECREASING CRANIAL COMPLICATIONS FOLLOWING DECOMPRESSIVE CRANIECTOMY FOLLOWING TRAUMA Presenter: Gail Tominaga

6c MISTREATMENT: THE PERSPECTIVE FROM SURGERY CLERKSHIP DIRECTORS Presenter: Cara Liebert

7c HAVING A FAMILY DURING SURGICAL RESIDENCY: IS IT POSSIBLE? Presenter: Cindy Kin

- 19 -

8c LAPAROSCOPIC SIMULATION FOR SURGICAL RESIDENTS: A KEY COMPONENT OF DEVELOPING LAPAROSCOPY IN UNDER-RESOURCED ENVIRONMENTS Presenter: Ellen Morrow

9c ARE U.S. SURGEONS AWARE THAT RACIAL DISPARITIES EXIST? THE HARD TRUTH Presenter: Breanne Britton

10c IS THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) SUPERIOR TO ADMINISTRATIVE DATABASES? A COMPARISON WITH THE NATIONWIDE INPATIENT SAMPLE Presenter: Anna Weiss

11c EFFECT OF OPERATING ROOM INEFFICIENCY ON HOSPITAL CHARGES FOR URGENT LAPAROSCOPIC CHOLECYSTECTOMY Presenter: Eric Campion

2:00 pm – 3:15 pm Scientific Session 3 Moderator Jason Lee

8 THROMBOEMBOLIC COMPLICATIONS FOLLOWING COLORECTAL SURGERY: ARE WE OVER-PROPHYLAXING? * RESIDENT PRIZE (Washington/Alaska/British Columbia Caucus) Presenter: Daniel Nelson Discussant: Glenn Ault Closer: Scott Steele

9 KEY CLINICAL FACTORS THAT DEFINE VENOUS THROMBOEMBOLISM RISK AFTER PEDIATRIC TRAUMA Presenter: Christopher Connelly Discussant: Robert Sawin Closer: Jennifer Watters

10 OVERTREATMENT OF HEPARIN-INDUCED THROMBOCYTOPENIA IN SURGICAL INTENSIVE CARE UNITS Presenter: David Hoang Discussant: Col. Matthew Martin Closer: Daniel Margulies

- 20 -

3:15 pm – 3:40 pm Afternoon Break with Industry Support3:40 pm – 4:55 pm Scientific Session 4 Moderator Vincent Rowe

11 SHOULD STATINS BE ADDED TO β -BLOCKERS AS A QUALITY METRIC FOR HIGH-RISK SURGICAL PATIENTS? BEYOND SCIP *NEW MEMBER PRIZE Presenter: William Toppen Discussant: Jason Lee Closer: Peyman Benharash

12 THREE-YEAR MORTALITY DECREASED AND RE-INTERVENTIONS INCREASED FOR EVAR OVER OPEN AORTIC ANEURYSM REPAIRS IN CALIFORNIA Presenter: David Chang Discussant: James Holcroft Closer: Eric Wilson

13 REDUCED EARLY MORTALITY AND IMPROVED DISCHARGE DISPOSITION FOLLOWING IMPLEMENTATION OF AN ENDOVASCULAR-FIRST STRATEGY TO RUPTURED AAAs Presenter: Brant Ullery Discussant: Peyman Benharash Closer: Jason Lee

SaturDay, February 21, 20157:45 am – 9:50 am Scientific Session 5 Moderator Jorge Reyes

14 IMPORTED KIDNEY GRAFTS FROM NON- CONVENTIONAL ADULT DECEASED DONORS SUCCESSFULLY INCREASE ACCESS TO TRANSPLANTATION FOR ELDERLY PATIENTS *RESIDENT PRIZE (Northern California Caucus) Presenter: Jakub Woloszyn Discussant: Lea Matsuoka Closer: Richard Perez

- 21 -

15 DAMAGE CONTROL: A STRATEGY TO MANAGE POST-REPERFUSION HEMODYNAMIC INSTABILITY AND COAGULOPATHY IN LIVER TRANSPLANTATION Presenter: Joseph DiNorcia Discussant: Marc Melcher Closer: Ronald Busuttil

16 LIVER TRANSPLANTATION PROVIDES LONG- TERM DISEASE FREE SURVIVAL IN CHILDREN WITH HEPATOBLASTOMA AND HEPATOCELLULAR CANCER Presenter: Thomas Pham Discussant: Linda Wong Closer: Andrew Bonham

17 KIDNEY TRANSPLANTATION IN THE HISPANIC POPULATION Presenter: Evan Alicuben Discussant: Waldo Concepcion Closer: Lea Matsuoka

18 INACCURACIES IN THE ACS-NSQIP DATABASE FOR HEPATIC SURGERY: FAILURE TO DETECT LIVER-SPECIFIC COMPLICATIONS Presenter: David Daar Discussant: Ronald Busuttil Closer: David Imagawa

9:50 am – 10:15 am Morning Break with Industry Support10:15 am – 10:45 am Historical Vignette 10:45 am – 12:15 pm President’s Forum and Town Hall

SunDay, February 22, 20157:45 am – 9:50 am Scientific Session 6 Moderator Steven Stain

19 GLOBAL SURGERY: DRIVERS OF ITS RECENT POPULARITY Presenter: Haile Debas Discussant: Susan Orloff Closer: Haile Debas

- 22 -

20 A CONSORTIUM APPROACH TO INTERNATIONAL SURGICAL EDUCATION IN A DEVELOPING COUNTRY: A PILOT PROGRAM AND EDUCATIONAL NEEDS ASSESSMENT Presenter: Mackenzie Cook Discussant: Stephen Bickler Closer: William Schecter

21 GLOBAL HEALTH INFORMATICS AND ONCOLOGY: A PILOT PROGRAM IN AFFORDABLE NETWORK TECHNOLOGIES IN A LOW-INCOME COUNTRY Presenter: Ahmed Rahim Discussant: Shawn Steen Closer: Pierre Theodore

22 A MULTIDISCIPLINARY DISEASE-SPECIFIC ROTATION CAN BE SUCCESSFULLY INCORPORATED INTO SURGICAL RESIDENCY Presenter: Amanda Graff-Baker Discussant: Kristine Calhoun Closer: Karen Deveney

23 RESIDENT ATTITUDES AND STUDY HABITS ARE PREDICTIVE OF AMERICAN BOARD OF SURGERY IN-TRAINING EXAMINATION (ABSITE) SCORES Presenter: Jerry Kim Discussant: Karen Deveney Closer: Farin Amersi

9:50 am – 11:30 am Scientific Session 7 Moderator Karen E. Deveney

24 EXTRANODAL EXTENSION ON SENTINEL LYMPH NODE DISSECTION IN THE ACOSOG z011 ERA: DOES SIzE MATTER? Presenter: Audrey Choi Discussant: Amanda Wheeler Closer: Maheswari Senthil

- 23 -

25 MOLECULAR MARKER EXPRESSION IS HIGHLY HETEROGENEOUS IN ESOPHAGEAL ADENOCARCINOMA AND DOES NOT PREDICT A RESPONSE TO NEOADJUVANT THERAPY Presenter: Nathan Bronson Discussant: Jeffrey Norton Closer: James Dolan

26 DETERMINANTS OF VALUE IN PANCREATIC SURGERY Presenter: Erin Brown Discussant: Clifford Ko Closer: Richard Bold

27 ARE PATIENTS WITH BILATERAL ADRENAL INCIDENTALOMAS SIMILAR TO THOSE WITH UNILATERAL LESIONS? Presenter: Jesse Pasternak Discussant: Philip Haigh Closer: Quan-Yang Duh

11:30 am – 12:00 pm Business Meeting

- 24 -

Scientific SessionsPapers 1-27

All Scientific Session and E-Poster Presentation authors and presenters are MDs unless otherwise noted.

- 25 -

[1]PeriProStHetic aneStHetic For PoStoPeratiVe

PAIN AFTER LAPAROSCOPIC VENTRAL HERNIA REPAIR:a ranDomizeD, PLacebo controLLeD triaL* RESIDENT PRIZE FINALIST (Southern California Caucus)

Authors: A. E. Gough1, S. S. Chang3, S. Reddy2, L. Ferrigno1, J. Grotts1, S. Yim1, D. S. Thoman1

Institutions: 1Santa Barbara Cottage Hospital, 2Cleveland Clinic, 3Community Hospital of the Monterey Peninsula

Presenter: Aimee GoughDiscussant: Susan Rowell

Closer: David Thoman

Importance: Laparoscopic ventral hernia repair (LVHR) using mesh is a well-established intervention for ventral hernia, but pain control can be challenging.Objective: To determine if instillation of long-acting local anesthetic between the mesh and the peritoneum after LVHR reduces pain or narcotic requirements.Design: A prospective, double-blinded, randomized controlled trial with data collection over three years comparing long-acting local anesthetic (bupivacaine) or placebo (saline) injected between the mesh and peritoneum, and into the abdominal wall musculature.Setting: A tertiary care, community teaching hospital.Participants: Of 120 screened patients undergoing LVHR, 99 eligible patients were randomized; of those, 42 received study medication and 38 received placebo.  Patients with a history of chronic narcotic use were excluded.Main Outcome Measures: Post-operative pain using a standard scale of 0-10, and narcotic medication use in IV morphine equivalents were measured and compared.

- 26 -

Results: Baseline and operative characteristics were similar except that the treatment group was significantly older (61.8 vs. 52.3 years old, p = 0.001).  Postoperatively, pain score in the recovery room (4.7 vs. 3.2, p = 0.003), interval total narcotic use (12.5 mg vs. 6.7 mg, p = 0.003 at less than four hours; 2.7 mg vs. 0 mg, p = 0.014 at 8-12 hours), and total IV narcotic use (17.2 mg vs. 9.2 mg, p = 0.03) were all significantly less in the treatment group. There were no adverse events.Conclusions: Administration of a long-acting local anesthetic significantly reduces post-operative pain and narcotic use after LVHR.

- 27 -

[2]robotic-aSSiSteD coLorectaL Surgery in tHe

UNITED STATES:AN UPDATED ANALYSIS OF NATIONWIDE TRENDS

anD outcomeSAuthors: M. H. Hanna, G. S. Hwang, M. J. Phelan,

J. C. Carmichael, S. D. Mills, A. Pigazzi

Institution: University of California – Irvine

Presenter: Mark HannaDiscussant: Vassiliki Tsikitis

Closer: Alessio PigazziImportance: Robotic-assisted colorectal surgery (RACS) is becoming increasingly popular, yet data comparing its outcomes remains limited. Objective: Identify trends and outcomes of RACS nationwide and then compare them to the more established technique of Laparoscopic-assisted colorectal surgery (LACS). Design, Setting and Participants: Nationwide Inpatient Sample (NIS) database was used to retrospectively identify all patients that underwent RACS and LACS for cancer, benign and diverticular disease over the period of 2009-2012.  Trends in different hospital settings and indications were analyzed.  Multivariate logistic regression was used to compare postoperative outcomes. Main Outcome Measures: Trends and postoperative outcomes of RACS vs. LACS. Results: An estimated 281,877 colorectal procedures were preformed through 2009-2012 using minimally invasive techniques, with RACS accounting for 5% of cases. RACS progressively increased in frequency in all hospital settings with the majority of cases being done in large, urban and teaching hospitals.  Diverticulitis was the most common indication for RACS by 2012.  On multivariate analysis RACS was associated with shorter LOS (Rectal:-0.72, 95%CI -1.04to-0.40, Colonic: -0.36, CI95% -0.56to-0.16); lower anastomotic leak (Rectal: AOR=0.6, P=0.0078, Colonic: AOR=0.65, P=0.0078); lower conversion (Rectal: AOR=0.07, P<0.00001, Colonic: AOR=0.36, P<0.00001); lower ileus/bowel obstruction (Rectal:

- 28 -

AOR=0.74, P=0.0082, Colonic: AOR=0.86, P=0.0082); higher hospital charges (Rectal: $10623.47, 95%CI 6562.04-14684.90, Colonic: $12114.34, 95%CI 9667.60-14561.09) compared to LACS.  No significant differences were found in overall mortality, morbidity, and post-operative bleeding. Conclusions: Use of RACS is limited but increasing nationwide. RACS is associated with higher hospital charges but lower anastomotic leak, conversion rate, LOS and postop ileus/bowel obstruction compared to LACS.  

- 29 -

[3]coSt-eFFectiVeneSS anaLySiS oF inguinaL Hernia

rePair in unDocumenteD immigrantSAuthors: A. Afshar, J. G. Kahn, W. P. Schecter

Institution: University of California - San Francisco

Presenter: Ariana AfsharDiscussant: Arvin Gee

Closer: William Schecter

Importance: The cost of providing charity surgical care for undocumented immigrants and the downstream savings and health benefits are poorly understood. Objective: To calculate the cost-effectiveness of tension-free inguinal herniorrhaphy for undocumented immigrant patients. Design: A decision tree-based cost-effectiveness model was used to compare timely to no timely surgery. Clinical input values, including the long-term likelihood of hernia emergencies, were derived from published literature, and costs from provider cost records. Sensitivity analyses were performed to evaluate the impact of key inputs on the results. Setting: Charitable care for undocumented patients in a large medical center. The base case patient was a male 35 years of age or older with symptomatic primary unilateral inguinal hernia. The interventions compared were elective outpatient inguinal hernia surgery versus no elective hernia surgery. Main Outcome Measures: Net intervention costs, quality-adjusted life years (QALY) gained, and incremental cost-effectiveness ratios. Results: In the base case analysis, timely hernia repair had a cost of $4414 USD for 24.45 quality-adjusted life years, compared with $1437 USD and 20.47 quality-adjusted life years for no timely surgical repair. The incremental cost-effectiveness ratio was $747 USD per QALY gained. Sensitivity analyses suggested that the outcome was predominantly affected by the chronic pain variable.  The base case model results remained robust to plausible variations of model parameters. Conclusions: The estimated cost-effectiveness ratio is far below the willingness to pay threshold in the United States. Timely elective inguinal herniorrhaphy is very cost-effective in this setting.

- 30 -

[4]naturaL HiStory oF inDeterminate bLunt

cerebroVaScuLar inJury *RESIDENT PRIZE FINALIST (Oregon/Hawaii Caucus)

Authors: J. D. Crawford, K. M. Allan, K. U. Patel, A. F. Azarbal,E. L. Mitchell, T. K. Liem, G. L. Moneta, G. J. Landry

Institution: Oregon Health and Science University

Presenter: Jeffrey CrawfordDiscussant: Karen WooCloser: Gregory Landry

Importance: The Denver criteria grade blunt cerebrovascular injuries (BCVI) but fail to capture many patients with indeterminate findings on initial imagingObjective: Evaluate outcomes and clinical significance of indeterminate BCVI (iBCVI). Design, Setting, Participants: A retrospective review of patients treated for BCVI from 2005-2014 was completed. Patients were divided into two groups; true BCVI as defined by the Denver criteria and iBCVI which was any initial imaging suggestive of a cerebrovascular arterial injury not classifiable by the Denver criteria.Main Outcome Measure(s): Primary outcomes were rate of resolution of iBCVI and freedom from CVA/TIA.   Results: We identified 100 patients with 138 BCVIs, 78 with true BCVI and 59 with iBCVI (Table 1).  76% of iBCVI resolved or remained unchanged while 24% progressed to true BCVI with serial imaging. Rate of CVA/TIA in the iBCVI was 5.1% compared to 13.9% in the true BCVI group (p=0.09).  Of the 14 total CVA/TIAs 10 resulted from carotid injury and 4 from vertebral artery occlusion. There was no difference in freedom from CVA/TIA for the two groups (Figure 1) or treatment with antiplatelets v. antiplatelet plus an anticoagulant. Median clinical follow-up was 90 days. Conclusions: Detection of iBCVI has become a common clinical conundrum with improved and routine imaging. iBCVI is not completely benign with 24% demonstrating anatomic progression to true BCVI and 5% developing cerebrovascular symptoms. We therefore recommend serial imaging and antiplatelet therapy for iBCVI. 

- 31 -

- 32 -

[5]inter-HoSPitaL Variation in mortaLity For

PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY: DoeS comPLiance WitH eViDence-baSeD

guiDeLineS matter?Authors: A. J. Dawes1,2,3, G. D. Sacks1,2, H. G. Cryer1, C. Preston, RN4,

D. Gorospe, RN4, J. P. Gruen6, M. Cohen, RN1, D. McArthur1, M. M. Russell1,3, M. Maggard-Gibbons1,3, C. Y. Ko 1,3

Institutions: 1University of California - Los Angeles 2Robert Wood Johnson Clinical Scholars Program 3 VA Greater Los Angeles Healthcare System

4 Los Angeles County Department of Health Services 6 University of Southern California

Presenter: Aaron DawesDiscussant: Martin Schreiber

Closer: H. Gill Cryer

Importance: Compliance with evidence-based guidelines in traumatic brain injury (TBI) has been proposed as a marker of quality, however, the association between hospital-level compliance rates and risk-adjusted clinical outcomes remains poorly understood.  Objective: To examine whether hospital-level compliance with Brain Trauma Foundation (BTF) guidelines for ICP monitoring and craniotomy is associated with risk-adjusted mortality in severe TBI.   Participants: All patients (n=843) presenting to a regional consortium of 14 hospitals between 2009-2010 with severe TBI (blunt head trauma, Glasgow Coma Scale [GCS] ≤ 8, abnormal intracranial findings on head computed tomography [CT]). Main Outcome Measures: We developed a multilevel mixed effects model for inpatient mortality after adjusting for demographics, severity of trauma (e.g. mechanism of injury, injury severity score [ISS]), and TBI-specific variables (e.g. cranial nerve reflexes, head CT findings). Observed-to-expected (O/E) mortality ratios were calculated for each hospital as a measure of risk-adjusted performance. Rates of compliance for ICP monitoring and craniotomy were compared across ranked terciles of hospitals.  

- 33 -

Results: We found widespread variation in compliance across hospitals, but no association between hospital-level compliance rates and risk-adjusted performance (Table). Unadjusted mortality rates varied by site from 25.4-52.2%; O/E ratios ranged from 0.61-1.27. Hospital-level compliance ranged from 9.6-62.3% for ICP monitoring and 6.3-75.0% for craniotomy. Conclusions: Overall, only 45% (381/843) of patients with an appropriate indication underwent ICP monitor placement and only 39% (151/385) underwent craniotomy. Hospital-level compliance with evidence-based guidelines has minimal association with risk-adjusted outcomes. Given the complexity of TBI care, outcome-based metrics, including functional recovery, may be more accurate than process measures at determining hospital quality.

- 34 -

[6]emergency abDominaL Surgery

IN THE CRITICALLY-ILL: WHen iS it FutiLe?

Authors: N. Lu, A. Marumoto, BS, L. L. Wong

Institution: University of Hawaii

Presenter: Ning LuDiscussant: Daniel Margulies

Closer: Linda Wong

Importance: Abdominal surgery is risky in critically-ill patients and contributes to the high cost of healthcare in the U.S. Objective: Identify predictors of 30-day mortality in intubated patients requiring emergent abdominal surgery. Design: Retrospective review of the NSQIP database 2005 - 2012. Current Procedural Terminology (CPT) codes for common emergency abdominal procedures and ventilator status were used to identify “critically ill” patients. Used Chi-Square/regression analysis to determine predictors of 30-day mortality. Setting: 373 hospitals participating in NSQIP. Participants: Patients at these hospitals Main Outcome Measures: 30-day mortality, length of stay, and predictors of 30-day mortality. Results: Of the 4901 patients, 53% were male, 52.2% were > 65 years, overall 30-day mortality was 44.2%. (mean time to death of 6.75 days). More procedures were associated with increased mortality. Pre-operative factors best predicting 30-day mortality included:  age >65 (OR 1.91, 95%CI 1.67-2.17), esophageal varices (OR 3.54, 95%CI 1.68-7.49), disseminated cancer (OR 2.23, 95% CI 1.65-3.02), and sepsis (OR 1.64, 95%CI 1.35-2.00)

- 35 -

Conclusions: Nearly half of intubated patients who undergo abdominal surgery die within 30 days. Mortality increases with each additional procedure.  This risk should be discussed with the option to transition to palliative care in patients with particularly high risk, including those with advanced age, liver disease, cancer or sepsis.  

- 36 -

[7]ALL AIR IN THE MEDIASTINUM IS NOT EQUAL:

ct FinDingS anD mortaLity in PatientS WitH PneumomeDiaStinum From bLunt trauma

Authors: V. E. Chong, W. S. Lee, G. P. VictorinoInstitution: University of California San Francisco-East Bay

Presenter: Vincent ChongDiscussant: Christian de Virgilio

Closer: Gregory VictorinoImportance: The significance of pneumomediastinum in patients injured by blunt trauma is controversial. Computed tomography (CT) scan findings may help prognosticate patient survival. Objective: To identify CT-scan findings associated with mortality in patients with pneumomediastinum due to blunt trauma.Design: Retrospective chart review from 2002-2011.Setting: University-based urban trauma center.Participants: Patients injured by blunt trauma found to have pneumomediastinum on initial chest CT scan.Main Outcome Measures: In-hospital mortality.Results: During the study period, 3,327 patients with blunt trauma underwent chest CT. Of these, 72 (2.2%) had pneumomediastinum. Patients with pneumomediastinum had higher injury severity score (p<0.05) and chest abbreviated injury score (p<0.001) than those without. Pneumomediastinum was associated with higher mortality (12.5% vs. 3.6%; p<0.001) and longer hospital (11 days vs. 5 days; p<0.001), intensive care (5.4 days vs. 1.8 days; p<0.001), and ventilator days (1.7 days vs. 0.6 days; p<0.05). We evaluated several chest CT findings that may have predictive value. Pneumomediastinum size was not associated with in-hospital mortality (p=0.22). However, location of air in the posterior mediastinum or in all mediastinal compartments were both associated with increased mortality (p<0.05). Presence of pleural effusion along with pneumomediastinum was also associated with mortality (22% vs. 3%, p<0.05)Conclusions: Though uncommon in patients with injury from blunt trauma, CT findings of posterior pneumomediastinum, air in all mediastinal compartments, and concurrent pleural effusion were associated with increased mortality. These CT findings could be used as a triage tool to alert the trauma surgeon of a potentially lethal injury.  

- 37 -

[8]tHromboemboLic comPLicationS FoLLoWing

COLORECTAL SURGERY: ARE WE OVER-PROPHYLAXING? *RESIDENT PRIZE FINALIST (Washington/Alaska/

British Columbia Caucus)

Authors: D. W. Nelson1, V. V. Simianu2, A. Bastawrous3, R. Billingham3, A. Fichera2, M. Florence3, E. K. Johnson1, M. Johnson4, R. Thirlby5,

D. Flum2, S. R. Steele1

Institutions: 1Madigan Army Medical Center, 2University of Washington, 3Swedish Medical Center, 4Skagit Valley Medical Center,

5Virginia Mason Medical Center

Presenter: Daniel NelsonDiscussant: Glenn Ault

Closer: Scott SteeleImportance: Colorectal operations are associated with an increased 90-day venous thromboembolic (VTE) risk.   Objective: Characterize the incidence and risk factors associated with thromboembolic complications following colorectal surgery. Design: Prospective data from Washington State Surgical Care and Outcomes Assessment Program (SCOAP) linked to statewide hospital discharge database. Setting: Diverse mix of Washington state hospitals. Participants: Patients undergoing colorectal surgery (2006 - 2011) at 52 SCOAP hospitals.   Main Outcome Measure(s): VTE complications up to 90 days after colorectal surgery. Results: From 16,161 patients (mean age 61.4; 54% female), preoperative and in-hospital VTE use chemoprophylaxis increased significantly, reaching 81% and 86%, respectively, by 2011 (p<0.001). Overall, 9% (n=1,400) were discharged on chemoprophylaxis. The incidence of VTE complications was 2.3% (n=363).  VTE rates were higher in those receiving chemoprophylaxis compared to patients not receiving chemoprophylaxis (p<0.05).

- 38 -

Abdominal operations had higher rates of 90-day VTE compared to pelvic operations (2.6% vs 1.8%, p<0.001). Cancer operations had lower incidence of VTE compared to non-malignant processes (1.1% vs 1.5% in-hospital VTE, p=0.05 and 2.1% vs 2.4% 90-day VTE, p=0.24). On adjusted analysis, age, males, BMI >30, non-elective surgery, and inflammatory conditions were associated with increased risk of VTE complications (p<0.05). Discharge chemoprophylaxis was paradoxically associated with increased risk of VTE complications (OR=2.72; CI=1.36-5.47; p=0.005).   Conclusions and Relevance: Overall VTE rates remain low and largely unchanged. The increase in VTE with perioperative chemoprophylaxis may reflect appropriate selective prophylaxis for at-risk patients and higher detection rates rather than truly increased VTE incidence. These data should influence future prophylaxis guidelines.

- 39 -

[9]key cLinicaL FactorS tHat DeFine VenouS

tHromboemboLiSm riSk aFter PeDiatric traumaAuthors: C. R. Connelly1, B. S. Diggs1, J. S. Barton2, P. E. Fischer, NREMT-P3,

S. Krishnaswami1, M. A. Schreiber1, J. M. Watters1

Institutions: 1Oregon Health and Science University, 2University of Texas Health Science Center at Houston, 3Carolinas Medical Center

Presenter: Christopher ConnellyDiscussant: Robert SawinCloser: Jennifer Watters

Importance: Although rare, incidence of venous thromboembolism (VTE) in pediatric trauma patients is increasing and consequences of VTE in children are significant.  Previous studies demonstrated increasing VTE risk in older pediatric trauma patients and improved VTE rates with institutional interventions. While national evidenced-based guidelines for VTE screening and prevention are currently in place for adults, none exist for pediatric patients. Objective: Define relevant clinical factors associated with VTE in children after trauma, which may be used to develop screening and prophylaxis guidelines in this population. Design: Retrospective review of pediatric patients aged 0-21 years using the National Trauma Data Bank (NTDB), years 2007-2012. Classification model created using conditional inference by binary recursive partitioning to discriminate clinical factors most strongly associated with VTE. Setting: Trauma centers reporting to NTDB. Participants: 991580 pediatric patients entered in the NTDB. Main Outcome Measures: Diagnosis of pulmonary embolism or deep venous thrombus (VTE) in pediatric trauma patients. Results: VTE diagnosed in 3263 children (overall rate 0.33%). Multivariate logistic regression analyzing the rate of VTE and associated risk factors performed and consistent with previously published results. Primary factors associated with VTE identified by classification tree modeling are intensive care unit length of stay (ICU LoS), cardiac, vascular and spleen surgery, hospital length of stay (LoS), age, and ventilator days.

- 40 -

Conclusions: VTE screening should begin in all pediatric trauma patients hospitalized greater than five days.  In the ICU, screening should begin at hospital day 3, initiating prophylaxis in patients who have undergone cardiac, vascular or spleen surgery, as soon as bleeding risks are acceptable.

- 41 -

[10]oVertreatment oF HeParin-inDuceD

tHrombocytoPenia in SurgicaL intenSiVe care unitS

Authors: D. M. Hoang, A. zaw, J. Murry, D. Mehrzadi, BA, T. Lee, BS, R. Mason, Pharm. D., D. R. Margulies, E. J. Ley

Institution: Cedars-Sinai Medical Center

Presenter: David HoangDiscussant: Col. Matthew Martin

Closer: Daniel Margulies

Importance: Recent studies reveal high incidence of over-diagnosis of Heparin-Inducted Thrombocytopenia (HIT) in surgical patients with critical illness. The optimal criteria for diagnosis of HIT remain unclear, contributing to unnecessary treatment. Objective: After raising our screening threshold for HIT diagnosis from PF4 0.4 to 0.84, we reviewed how often patients were correctly treated. Design: From January 1, 2011 through August 1, 2014, we prospectively collected data including Age, Sex, PF4, SRA, and 4T scores. HIT-positive patients were defined as those with positive SRA. Setting: Urban tertiary medical center. Participants: SICU patients receiving PF4, SRA, and 4T scores. Main Outcomes and Measures: Threshold diagnostic criteria to initiate HIT therapy. Results: A total of 136 patients had PF4, SRA, and 4T scores. Positive SRA were noted in 12/136 (9%) patients. With PF4>2.0, 9/11 (81%) of patients who had positive SRA compared to 1/22 (4.5%) of patients with PF4 .85 to 2.0, and 1/103 (1.0%) of patients with PF4 0.0 to .84. A total of 29/136 (21%) patients received treatment with argatroban, lepirudin, or fondaparinux: 11/12 (92%) of HIT-positive compared to 18/124 (15%) of HIT-negative patients. All HIT-positive patients with suspicion or evidence of thrombus 11/11(100%) received treatment

- 42 -

Measure Sensitivity Specificity Positive Predictive Value

Negative Predictive Value

PF4>0.40 91.7% 44.4% 13.8% 98.2%

PF4>0.84 83.3% 81.5% 30.3% 98.1%

PF4>2.0 75.0% 98.4% 81.8% 97.6%

4T>3 583.% 88.7% 33.3% 95.7%

4T>6 41.7% 88.7% 26.3% 94.0%

Conclusions: HIT in the surgical ICU requires threshold criteria to help determine who should receive therapy. Treating patients suspected of HIT for PF4>0.84 before SRA confirmation leads to unnecessary anticoagulation therapy. PF4>2.0 may be an appropriate threshold to consider HIT treatment in patients who are not at bleeding risk.  

- 43 -

[11]SHOULD STATINS BE ADDED TO β -BLOCKERS AS A

QuaLity metric For HigH-riSk SurgicaL PatientS? beyonD SciP

* NEW MEMBER PRIZE

Authors: W. Toppen, S. Sareh, L. Mukdad, D. Johansen, N. Satou, R. Shemin, P. Benharash

Institution: David Geffen School of Medicine

Presenter: William ToppenDiscussant: Jason Lee

Closer: Peyman Benharash

Importance: Following the Surgical Care Improvement Project, preoperative ß-blockers are widely used as a quality metric for cardiac surgery. Recently, preoperative statins have also been suggested to improve outcomes. Objective: Determine if preoperative ß-blockers, statins, or both are associated with decreased adverse events. Design: Retrospective review of an institutional database of cardiac surgery patients between 2008 and 2014 (N=3826). Data for baseline and procedural characteristics, including ß-blockers and statin administration in the 24 hours preceding surgery, were gathered. A multivariate regression model was utilized to characterize the association between medication administration and in-hospital mortality as well as secondary outcomes including length of stay, prolonged mechanical ventilation, reoperation for bleeding, postoperative atrial fibrillation, and renal failureSetting: Large academic center Participants: Patients were divided into no-treatment (NONE), or three treatment groups based on administration of ß-blockers, statins, or BOTH within 24 hours of surgery. Patients were excluded for incomplete records, trauma, transplant procedures, and history of arrhythmia. Main Outcome Measures: In-hospital mortality Results: A total of 2506 patients met inclusion criteria (ß-blockers: 536 (21.4%), Statins: 396 (15.8%), BOTH: 948 (37.4%), NONE: 636 (25.4%)).

- 44 -

On multivariate analysis, mortality was similar amongst all groups. When compared to the NONE group, the BOTH group saw less prolonged ventilation, prolonged stay and reoperations for bleeding (TABLE 1).Conclusions: Preoperative ß-blockers or statins alone are not shown to be associated with improved outcomes following cardiac surgery. However, statins and ß-blocker together may improve several measures of morbidity. Large-scale trials are warranted to evaluate these observed benefits.

- 45 -

[12]tHree-year mortaLity DecreaSeD anD

re-interVentionS increaSeD For eVar oVer oPen aortic aneurySm rePairS in caLiFornia

Authors: D. C. Chang1, 2, R. Parina2, S. E. Wilson3

Institutions: 1Massachusetts General Hospital, 2University of California - San Diego, 3University of California - Irvine

Presenter: David ChangDiscussant: James Holcroft

Closer: Eric Wilson

Importance: The long-term survival and outcomes of open and endovascular abdominal aortic aneurysm (AAA) repair have not been studied on a population level outside a controlled trial setting. Objective: To determine long-term survival and outcomes of AAA repair patients in a large state. Design: Longitudinal analysis of the California Office of Statewide Health Planning and Development statewide database. Setting: California statewide from 2001-2009. Participants: Open and EVAR patients. Main Outcome Measures: 30-day complications, long-term mortality repeat AAA repair, incisional hernia repair and lower extremity amputation for up to 9 years. Results: A total of 24,157 patients were included in the study of who 52% underwent an endovascular repair. 30-day outcomes, including readmission, mortality, surgical site infection, sepsis, UTI, pneumonia and VTE were all found to be statistically significantly higher for open repair. Long-term mortality was statistically significantly higher for open repair until 3 years post-operatively. After 3 years, no significant difference in mortality was found between endovascular and open repair. Open repair was found to be associated with a higher rate of requiring a subsequent incisional hernia repair, but with a significantly lower rate of repeat AAA repair. See Table 1 for results of multivariate analyses.

- 46 -

conclusions: While endovascular AAA repair shows some early advantage in mortality over an open approach, this advantage disappears after 3 years. On the other hand, EVAR was associated with a significantly higher rate of re-intervention.   

- 47 -

[13]reDuceD earLy mortaLity anD imProVeD

DiScHarge DiSPoSition FoLLoWing imPLementation oF an enDoVaScuLar-FirSt

Strategy to ruPtureD aaasAuthors: B. W. Ullery, V. Chandra, M. W. Mell, E. J. Harris,

R. L. Dalman, J. T. LeeInstitution: Stanford University

Presenter: Brant UlleryDiscussant: Peyman Benharash

Closer: Jason LeeImportance: Mortality after open repair of ruptured abdominal aortic aneurysms (rAAA) remains high.  The role and clinical benefit of emergent endovascular aneurysm repair (EVAR) has yet to be fully elucidated. Objective: To evaluate the influence of an endovascular-first approach to patients with rAAA on perioperative mortality and associated early clinical outcomes. Design: Retrospective review of rAAAs from July 1997 to July 2014.Setting: Academic vascular practice. Participants: Consecutive series of patients with rAAA before (1997-2006) and after (2007-2014) implementation of an endovascular-first treatment strategy. Main Outcome Measures: Perioperative and one-year mortality, perioperative morbidity, and discharge disposition. Results: 88 patients with rAAA were included for analysis, including 46 in the pre- (87.0% open, 13.0% EVAR) and 42 in the post-EVAR intention to treat protocol groups (33.3% open, 66.7% EVAR, P=0.001). Baseline demographics were similar. Patients post-protocol had significantly less procedural blood loss (1.9 L vs. 3.9 L, P=0.01) and were less likely to develop ≥1 major postoperative complications (45.2% vs. 71.7%, P=.02). A significant reduction in perioperative (16.7% vs. 37.0%, P=0.05) and one-year (22.2% vs. 55.0%, P=.03) mortality was observed in the post-protocol group. Among hospital survivors, more patients in the post-protocol period were discharged to home rather than rehabilitation facilities (65.7% vs. 37.9%, P=0.04). Conclusions: Implementation of an endovascular-first strategy to the treatment of rAAA is associated with decreased early mortality, as well as a higher likelihood of being discharged to home. Patients with rAAA and appropriate anatomy should be offered endovascular repair as first-line treatment at experienced vascular centers.

- 48 -

[14]imPorteD kiDney graFtS From

non-conVentionaL aDuLt DeceaSeD DonorS SucceSSFuLLy increaSe acceSS to

tranSPLantation For eLDerLy PatientS * RESIDENT PRIZE FINALIST (Northern California Caucus)

Authors: J. Woloszyn, C. Troppmann, A. DeMattos, R. PerezInstitution: University of California - Davis

Presenter: Jakub WoloszynDiscussant: Lea Matsuoka

Closer: Richard Perez

Importance: The new kidney allocation system assigns highest priority to candidates who are within 15 years of the donors’ age. Elderly patients awaiting kidney transplant (KTx) will thus be most disadvantaged.  Innovative strategies to maintain/expand access to KTx for this growing candidate group are urgently needed. Objective: To assess whether imported grafts from nonconventional adult deceased donors (NC-DDs) can increase access to KTx for elderly candidates. Design: Historical cohort study. Setting: Academic medical center. Participants: Recipients ≥60 years old of adult deceased donor KTxs from 01/2008 to 12/2013. Methods:  We defined the following donor characteristics as non-conventional: extended criteria (ECD), donation-after-cardiac-death (DCD), acute kidney injury (AKI), Hepatitis-C- or Hepatitis-B core-antibody-positive, or standard criteria (SCD) with cold ischemia time (CIT) >40 hours.  We compared outcomes of grafts from all adult donors recovered by our local OPO versus outcomes of NC-DD grafts imported from outside our OPO’s service area.  Main Outcome Measures: Graft and patient survival. Results: Donor characteristics and recipient outcomes (Table 1): 

- 49 -

Kaplan-Meier post-transplant patient survival curve (Graph 1):

conclusion: In spite of a significantly more challenging donor profile (more ECD, AKI, DCD; longer CIT), imported NC-DD grafts afforded their recipients the same long-term transplant patient survival benefit as local kidneys.  Regionally and nationally shared imported kidneys can be an important organ source for elderly recipients.  Broader implementation of this organ acceptance strategy would reduce wait time for elderly candidates and might help decreasing the high national kidney graft discard rates.

- 50 -

[15]DAMAGE CONTROL: A STRATEGY TO MANAGE

PoSt-rePerFuSion HemoDynamic inStabiLity anD coaguLoPatHy in LiVer tranSPLantation

Authors: J. DiNorcia, M. K. Lee, M. Harlander-Locke, F. M. Kaldas, A. zarrinpar, D. G. Farmer, H. Yersiz, R. W. Busuttil, V. G. Agopian

Institution: University of California - Los Angeles

Presenter: Joseph DiNorciaDiscussant: Marc Melcher

Closer: Ronald Busuttil

Importance: Damage control (DC) with intraabdominal packing and delayed reoperation is an accepted strategy in trauma and acute care surgery but has not been evaluated in liver transplantation (LT). Objective: To evaluate the incidence, effect on survival, and predictors of need for DC (intraabdominal packing with delayed biliary reconstruction) in LT patients with hemodynamic instability or coagulopathy following allograft reperfusion.   Design: Retrospective analysis Setting: Large transplant center Participants: Of 1813 adults undergoing LT (2/2002-7/2012), 150 (8.3%) required DC. Main Outcome Measures: Predictors of DC, effects on graft and patient survival. Results: Compared to recipients without DC, DC patients had higher MELD scores (33vs27;P <0.001); more frequent pretransplant hospitalization (72%vs48%;P<0.001), intubation (33%vs20%;P<0.001), vasopressors (23%vs11%;P<0.001), dialysis (50%vs30%;P<0.001), and prior major abdominal operations (48%vs22%;P<0.001) including prior LT (29%vs8.9%;P<0.001); greater operative blood transfusion requirements (37vs13 units;P<0.001), worse intraoperative base excess(-10.3vs-8.4;P<0.001), more frequent reperfusion syndrome (25%vs5.4%; P<0.001), and longer cold (430vs404 minutes; P=0.035) and warm (46vs41 minutes;P<0.001) ischemia times. DC patients requiring only packing

- 51 -

removal and biliary reconstruction (DC-DBR) had graft and patient survival equivalent to recipients not requiring DC and superior to DC recipients with multiple reoperations (DC-MR, Figure). Multivariate predictors of DC included prior transplant or major abdominal operation, higher MELD score, and greater warm and cold and ischemia times (Table).

Conclusions: This study represents the first large report of DC as a viable strategy for complex LT recipients with ongoing coagulopathy or hemodynamic instability following reperfusion. In DC recipients not requiring further operations, outcomes are excellent and comparable to recipients undergoing 1-stage LT.

- 52 -

[16]LiVer tranSPLantation ProViDeS Long-term

DiSeaSe Free SurViVaL in cHiLDren WitH HePatobLaStoma anD HePatoceLLuLar cancerAuthors: T. A. Pham, A. Gallo, W. Concepcion, C. Esquivel, C. Bonham

Institution: Stanford University

Presenter: Thomas PhamDiscussant: Linda WongCloser: Andrew Bonham

Importance: Hepatoblastoma (HBL) and hepatocellular cancer (HCC) are the most common primary hepatic malignancies in childhood.  Given the rarity of these childhood tumors and their propensity to present at advanced stages, updated long-term data is needed. Objective: To determine whether liver transplantation provides long term disease free survival for children with HBL or HCC. Design: Single institution retrospective chart review spanning from 1990 to 2013. Setting: University Multi-Organ Transplant Center Participants: Patients less than 18 years of age who underwent liver transplantation for treatment of HBL or HCC.  There were a total of 40 patients; 30 diagnosed with HBL, 10 with HCC spanning from the year 1990 to 2013. Main Outcome Measures: Disease free survival and recurrenceResults: Using a Kaplan-Meier survival analysis, 1-, 5-, and 10-year disease free survival after OLTx was 90%, 79%, 79% for HBL and 87%, 75%, and 75% for HCC, respectively (log rank=0.81) (Figure 1). Overall patient survival showed similar results suggesting that most survivors were disease free.  Recurrence of disease occurred less than four years from transplant for both HBL and HCC.  The recurrence at 3 years was 13.7% and 22% for HBL and HCC, respectively (p=0.83).

- 53 -

Conclusions: Liver transplantation for advanced HBL and HCC is an excellent treatment that provides long-term disease free survival. Recurrence remains low and usually occurs within four years but may be amenable to further resection or adjuvant therapies. Future studies will assess the effectiveness of neoadjuvant therapies in combination with liver transplantation to decrease tumor recurrence.  

- 54 -

[17]kiDney tranSPLantation in tHe HiSPanic

PoPuLationAuthors: E. Alicuben, S. Alexopoulos, K. Woo, Y. Qazi, R. Dhawan, Y. Genyk,

R. Selby, L. MatsuokaInstitution: University of Southern California

Presenter: Evan AlicubenDiscussant: Waldo Concepcion

Closer: Lea Matsuoka

Importance: Hispanic race and low socioeconomic status are established predictors of disparity in access to kidney transplantation. However, their effects on post-operative patient and graft survival are controversial. Objective: To determine whether Hispanic race or public insurance predicted kidney transplant recipient graft and survival outcomes. Design: Retrospective review. Setting: Tertiary care hospital.Participants: 720 patients underwent kidney transplantation from January 1, 2004 to December 31, 2013, including 398 Hispanic patients and 322 non-Hispanic patients. Main Outcome Measures: Patient and graft survival and risk factors.Results: Hispanic patients were significantly younger (p<0.0001), on hemodialysis for longer (p=0.0018), had a greater percentage with public insurance (p<0.0001), and more commonly had diabetes as the cause of end-stage renal disease (p=0.0167) compared to non-Hispanic patients.  Hispanic patients had a significantly lower percentage of living donors (p=0.0013) but younger overall mean donor age (p=0.0004).  There was no difference in one and three-year graft (97% and 93% vs. 96% and 91%, p=0.18) or patient survival (98% and 97% vs. 98% and 95%, p=0.11) between the Hispanic and non-Hispanic recipients. Multivariate analysis identified increased recipient age and donor hypertension to be predictive of lower graft survival and increasing recipient age and diabetes to be predictive of lower patient survival. Conclusions: There is no difference in graft and recipient survival between Hispanic and non-Hispanic kidney transplant patients and neither Hispanic race nor public insurance are risk factors for graft or patient survival. 

- 55 -

[18]inaccuracieS in tHe acS-nSQiP DatabaSe For

HEPATIC SURGERY: FAILURE TO DETECT LIVER-SPECIFIC comPLicationS

Authors: D. A. Daar, A. N. Demirjian, D. K. ImagawaInstitution: University of California - Irvine

Presenter: David DaarDiscussant: Ronald Busuttil

Closer: David Imagawa

Importance: Large centralized databases are being increasingly utilized to assess surgical outcomes. More importantly, reimbursement may become tied to these outcomes.Objective: To assess accuracy of liver resection data within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Design: Retrospective review of ACS-NSQIP data and a prospectively-maintained database over a seven-year period. Setting: Single-institution, inpatient hospital setting.Participants: Patients undergoing liver resection including partial, left, right, or extended hepatectomy. Main Outcome Measures: Primary outcomes included overall complication rate, length of surgical stay, and 30-day mortality rate. Overall outcomes were compared with paired t-tests; event concordance was measured using true positive and true negative rates. Results: Of the 93 liver resections in ACS-NSQIP, 12 were incorrectly classified (false positive rate, 12.9%). Of the 81 true liver resections reported (139 actually performed), ACS-NSQIP demonstrated high fidelity with the prospective database with respect to demographic and operative characteristics, mean length of surgical stay (6.62 ± 4.90 days vs 6.60 ± 4.91 days; national, 7.83 ± 7.30 days), and 30-day mortality rate (1.2% vs 1.2%; national, 2.3%). ACS-NSQIP underreported the overall complication rate (29.6% vs 43.2%; P < 0.001; national, 31.5%), with ACS-NSQIP failing to capture liver-specific complications including biliary leak, pleural effusion, post-operative ascites, biloma, and small bowel obstruction. Failure to include liver-specific complications decreased overall sensitivity to 68.6%.Conclusions: Overall reporting of liver resection data within ACS-NSQIP is generally robust, but our results suggest it may underreport complication rates. ACS-NSQIP may benefit from the inclusion of liver-specific complication variables.

- 56 -

[19]GLOBAL SURGERY: DRIVERS OF ITS RECENT

PoPuLarityAuthor: H. T. Debas

Institution: University of California - San Francisco

Presenter: Haile DebasDiscussant: Susan Orloff

Closer: Haile Debas

Objectives: (1) review the drivers of the impressive recent surge in popularity of global surgery; and (2) discuss how we might optimally guide and harness the enthusiasm of our trainees and faculty to maximize the contribution of this emerging field to surgical education. Design: Review development of global health and global surgery programs in the last 20 years Setting: North America, particularly the US. Main Outcome Measures: Number of academic global health and global surgery programs, their funding, and national/international impact. Results: Over 250 universities in the US and Canada and several departments of surgery have developed global health and global surgery programs, respectively. Other drivers for the popularity of global surgery are WHO, the inclusion of “Essential Surgery” in Disease Control Priorities, Third Edition, the most influential book for donors and policy makers; and World Bank recognition that surgical care is highly cost-effective strategy in population health. Conclusions: The leadership of Academic Surgery and Surgical Associations will be necessary to optimize the contribution of global surgery to surgical education and training in the 21st century. In part, the guidance will require defining and integrating an appropriate curriculum, and standardizing the requirements for partnerships and overseas training of US surgical residents. Strong leadership can come from a re-designed “Operation Giving Back” of the American College of Surgeons in partnership with such organizations as the Consortium of Universities for Global Health.

- 57 -

[20]a conSortium aPProacH to internationaL

SURGICAL EDUCATION IN A DEVELOPING COUNTRY: a PiLot Program anD eDucationaL neeDS

aSSeSSmentAuthors: M. R. Cook1, B. Howard3, A. Yu2, D. Grey5, P. Hofmann, DrPH4,

J. Peck1, W. Schecter3

Institutions: 1Oregon Health and Science University, 2University of California – Berkeley, 3University of California – San Francisco,

4Hofmann Medical Group, 5Kaiser California, Retired

Presenter: Mackenzie CookDiscussant: Stephen Bickler

Closer: William Schecter

Importance: Surgical disease is a global health priority, and improving surgical care requires local capacity building.  Single institution partnerships and missions are logistically limited. The Alliance for Global Clinical Training (AGCT), is a consortium of American surgical departments that aims to provide continuous educational support at a tertiary care hospital in Tanzania (TCHT). This is the first multi-institutional international surgical collaboration described in the literature. Objective: We hypothesized that a collaboration between the TCHT and the AGCT is feasible and has a positive effect on patient care and surgical education.Design: During a one-year pilot program, residents and faculty from four American academic surgical programs rotated at the TCHT as clinicians and teachers. Thereafter, anonymous surveys were analyzed along a 5 point Likert scale.  Free text answers were analyzed for common themesResults: AGCT volunteers were present for 10 months. 15 TCHT faculty and 22 TCHT residents completed the survey. Key results are presented in the table. Six areas of educational need were identified: 1) formal didactics, 2) increased clinical mentorship, 3) longer AGCT presence, 4) equitable distribution of teaching time, 5) improved coordination/language skills and 6) reciprocal exchange rotations at American hospitals.

- 58 -

Conclusions: A multi-institutional international partnership is possible and leads to perceived improvements in patient care and resident learning. AGCT surgeons must focus primarily on training Tanzanian surgeons rather than doing operations and simultaneously improve their Swahili skills. Future efforts will expand our presence, equitably divide teaching among all TCHT surgeons, and collaboratively develop a formal surgical curriculum.    

- 59 -

[21]GLOBAL HEALTH INFORMATICS AND ONCOLOGY: A PILOT Program in aFForDabLe netWork tecHnoLogieS in

a LoW-income countryAuthors: P. R. Theodore1, A. A. Rahim, BS1, A. J. Sawyer1, H. M. Mentis2,

J. F. Donovan1

Institutions: 1University of California - San Francisco, 2University of MarylandPresenter: Ahmed RahimDiscussant: Shawn SteenCloser: Pierre Theodore

Importance: Low- and Middle-Income Countries (LMIC) are expected to face a 75% increase in cancer deaths by 2020. As battles against non-communicable diseases are waged, the demands on underfunded healthcare systems to cre-ate affordable oncology infrastructure will become ever more acute. Objective: To investigate the effectiveness of inexpensive online collaborative tools designed to aid decision-making, treatment planning and education by permitting presentation of cases from resource-limited environments to health-care professionals in the developed world. Design: An Extensible Markup Language (XML) based asynchronous clinical collaboration system was built to present 60 cases involving a variety of clinical conditions across oncology and traumatic disease to U.S. Academic Medical Center (AMC) volunteer physicians. Setting: University Hospital (Haiti) and U.S. AMCs. Participants: 60 patients. Main Outcome Measures: 1. Efficiency of deriving consensus opinion. 2. Multi-disciplinary user engagement. 3. Percent radiograph sharing from LMIC to U.S. AMCs. 4. Direct influence on LMIC medical decision-making. Results: Clinicians from 3 U.S. AMCs, in collaboration with medical colleagues in Haiti, came to a consensus opinion regarding diagnoses and treatment strategy within 3 days on average (Range: 1-15 days). Digital images of immunohisto-chemical staining and x-rays and literature reviews of the case were transmitted to Haitian physicians via the collaboration platform in 85% of cases (51/60 cases). Treatment plan recommendations were transferred in 90% of cases (54/60 cases). Conclusions: In combination with the will to improve health among the planet’s poorest communities, low-cost collaborative technologies as demonstrated in this pilot may lessen the disparity between developed and developing countries.  

- 60 -

[22]a muLtiDiSciPLinary DiSeaSe-SPeciFic rotation

can be SucceSSFuLLy incorPorateD into SurgicaL reSiDency

Authors: M. R. Cook, A. Graff-Baker, A. Moren, K. Fair, L. Kiraly, S. Brown, V. T. De La Melena, S. Pommier, K. Deveney

Institution: Oregon Health and Science UniversityPresenter: Amanda Graff-Baker

Discussant: Kristine CalhounCloser: Karen Deveney

Importance: Incorporating deliberate practice (DP) into residency curricula may optimize education. DP includes protected time for education, continuous expert feedback and a focus on a limited number of technical skills. It is strongly associated with mastery level learning. Objective: Determine if a multidisciplinary breast rotation, (MBR) increases DP opportunities. Design: MBR was compared to a traditional community rotation (TCR) and a university surgical oncology service (USOS). Data is presented as mean±standard deviation. Setting: Academic surgical residency.Participants: General surgery residents. Exposure: Beginning in 2010, interns completed the 4-week MBR. Three days a week were spent in surgery and surgical clinic.  Half-days were in breast radiology, pathology, medical oncology, and didactics. Outcome Measure: Resident feedback and operative volume Results: 31 interns rated the opportunity to perform procedures significantly higher for MBR than TCR or USOS (4.6±0.6 vs. 4.2±0.9 and 4.1±1.0, p<0.05). MBR was rated higher than TCR on quality of faculty teaching and educational materials (4.5±0.7 vs 4.1±0.9 and 4.0±1.2 vs 3.5 ±1.0, p<0.05). Interns operated more on the MDB than on the USOS and were more focused on breast resections, lymph node dissections and port placements than on the TSR or USOS. Conclusions and Relevance: The MDB incorporates multidisciplinary care into a unique, disease-specific, and educationally-focused rotation. It is highly rated and affords a greater opportunity for DP than either the USOS or TCR.  DP is strongly associated with mastery learning, therefore, this novel rotation structure could maximize intern education in the era of limited work hours. 

- 61 -

[23]reSiDent attituDeS anD StuDy HabitS are

PreDictiVe oF american boarD oF Surgery IN-TRAINING EXAMINATION (ABSITE) SCORES

Authors: J. J. Kim1, D. Y. Kim1, A. H. Kaji1, E. D. Gifford1, M. E. Reeves4, K. Inaba14, J. M. Galante9, F. Amersi10, B. R. Smith11, M. L. Melcher12,

T. Donahue14, C. de Virgilio1

Institutions: 1Harbor-UCLA Medical Center, 4Loma Linda University School of Medicine, 9University of California – Davis, 10Cedars-Sinai Medical

Center, 11 University of California – Irvine, 12 Stanford University, 14University of California - Los Angeles

Presenter: Jerry KimDiscussant: Karen Deveney

Closer: Farin Amersi

Importance: Studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying exams. Objective: To identify resident factors associated with ABSITE performance.Design: An anonymous 39-item questionnaire including demographic information, past performance on standardized exams, reading habits, and sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of ABSITE. Setting: 15 residency programs, nationwide. Participants: 371 surgical residents. Main Outcome Measures: 2014 ABSITE scores. Results: There was a 74% response rate. Most respondents were male (61%) with a mean age of 29.9 years and the mean amount of studying was 13.4 hours/month (95% CI: 11.6 - 15.3). Univariate analysis identified factors positively correlated, negatively correlated, and not associated with ABSITE scores (Table). Multivariate analysis identified the following as having a positive correlation with ABSITE score: USMLE 2 (p<0.0001), MCAT (p=0.003), opinion of ABSITE importance (p<0.0001), and having an equal focus on patient care and ABSITE preparation during study (p=0.03).

- 62 -

Conclusions: Daily studying and textbook use were associated with higher ABSITE scores. USMLE 2 and MCAT scores as well as resident attitude regarding the importance of the ABSITE results were found to be independent predictors of ABSITE performance. Additional studies are needed to determine whether MCAT scores should be included during the residency selection process.    

- 63 -

[24]EXTRANODAL EXTENSION ON SENTINEL LYMPH NODE

DISSECTION IN THE ACOSOG Z011 ERA: DoeS Size matter?

Authors: A. H. Choi, S. Blount, M. C. Perez, C. C. De Paz Villanueva, S. A. Rodriguez, M. Surrusco, S. S. Lum, M. Senthil

Institution: Loma Linda University School of Medicine

Presenter: Audrey ChoiDiscussant: Amanda Wheeler

Closer: Maheswari Senthil

Importance: Based on the ACOSOG z011 exclusion criteria, patients with T1-T2 tumors with 1-2 positive sentinel lymph nodes (+SLN) are recommended to undergo axillary lymph node dissection (ALND) if extranodal extension (ENE) is present. Objective: To determine the impact of ENE size on nodal burden, disease recurrence and survival in patients meeting z011 criteria Design: Retrospective cohort study between 2000-2012. Median follow-up time was 61 (1-158) months. ENE was classified as ≤ 2 mm or > 2 mm Setting: Single tertiary cancer center Participants: T1-T2 breast cancer patients with 1-2 +SLN Main outcomes measures: Nodal burden, disease recurrence, overall survival Results: Of 225 patients, 160 (71.1%) had no ENE (ENE-), 23 (10.2%) had ENE ≤ 2 mm, and 42 (18.7%) had ENE > 2 mm on SLN dissection. Number of +LN differed significantly between ENE- and ≤ 2 mm groups (1.72 vs. 3.22, p=0.01), as well as ENE- and > 2 mm groups (1.72 vs. 4.26, p<0.01). Similar patterns were observed for non-SLN metastases (0.48 vs. 1.91, p=0.02; 0.48 vs. 2.95, p<0.01). While comparison of ENE- and >2 mm ENE groups showed trends toward increased recurrence (11.9% vs. 2.5% distant recurrences, p=0.09) and decreased survival rates (23.8% vs. 11.9% mortality, p=0.05), there were no significant differences between the ENE- and ≤ 2 mm groups. Conclusion: Despite increased nodal burden, patients with 1-2 positive SLN and ENE ≤ 2 mm demonstrated similar recurrence and survival as ENE- patients. Further investigation regarding completion ALND in patients with ENE ≤ 2 mm is warranted.  

- 64 -

[25]MOLECULAR MARKER EXPRESSION IS

HigHLy HeterogeneouS in eSoPHageaL aDenocarcinoma anD DoeS not PreDict a

reSPonSe to neoaDJuVant tHeraPyAuthors: N. W. Bronson, B. S. Diggs, Ph.D., G. Bakis, K. M. Gatter,

B. C. Sheppard, J. G. Hunter, J. P. Dolan

Institution: Oregon Health and Science University

Presenter: Nathan BronsonDiscussant: Jeffrey Norton

Closer: James Dolan

Importance: A reliable method to identify complete responders (pCR) or non-responders (NR) to neoadjuvant chemoradiation therapy (NEO) would dramatically improve the ability to tailor therapy for esophageal cancer.Objective: To investigate if a distinct profile of prognostic molecular tumor markers can predict pCR after NEO. Design: Retrospective cohort study. Setting: High-volume tertiary care hospital. Participants: Patients who underwent trimodality therapy for esophageal adenocarcinoma between 2000 and 2012. Main Outcome Measures: A pCR was defined as no evidence of malignancy on final pathologic examination and all others were classified as NR. Expression of p53, Her-2/neu, Cox-2, Beta-Catenin, E-Cadherin, MMP-1, NFkB, and TGF-B was measured by immunohistochemistry and graded by an experienced pathologist.  Molecular profiles comparing responders to non-responders were analyzed using classification and regression tree (CART) analysis to investigate response to NEO and overall survival. Results:19 patients were pCRs and 34 were NRs.  pCRs were more likely to be alive at follow up than NRs (p<0.01).  Thirty seven distinct molecular marker profiles were identified. Expression of molecular markers was highly heterogeneous between patients and did not correlate with a response to NEO, survival (p=0.47) or clinical stage (p=0.39) when evaluated either as individual markers (Fig 1) or in combination with other expression patterns (Fig 2).

- 65 -

Conclusions: Neoadjuvant therapy dramatically impacts survival through a mechanism independent of known molecular markers of esophageal cancer, which are expressed in a highly heterogeneous fashion and do not predict response to NEO or survival.

- 66 -

[26]DeterminantS oF VaLue in Pancreatic Surgery

Authors: E. G. Brown, D. Burgess, BSN, MHA, C. Li, Ph.D, R. J. Bold

Institution: University of California - Davis

Presenter: Erin BrownDiscussant: Clifford Ko

Closer: Richard Bold

Importance: Determining predictors of value is critical for success amidst current healthcare reform. Objective: To evaluate predictors of value among patients undergoing elective pancreaticoduodenectomy nationwide. Design: Retrospective review of administrative database Setting: Academic medical centers among the University Healthsystem Consortium Participants: 17,220 patients underwent elective pancreaticoduodenectomy at 135 academic medical centers between 10/2010-6/2014. Main Outcome Measures: A quality index score (QIS) was developed by totaling rank score (by quintiles) of five variables associated with optimal outcomes following pancreaticoduodenectomy: incidence of postoperative complications, length of stay, 30-day readmission rate, mortality rate, and hospital volume. Value was defined as hospital-based QIS divided by mean hospital charges. Hospitals in the top quintile for value were identified as high-value centers, while those in the bottom were designated low-value. Results: The majority of high value centers were top performers in only 1-2 of the 5 quality categories (78.6%) and 11% were low performers in at least one category; conversely, 41% of low value centers were a top performer in one category (Table).  Furthermore, high-value centers had significantly lower charges than low-value centers (p<0.001). The association between QIS and hospital charges was weak (R2=0.012).  Lastly, high value centers were most likely to be from the South (46.4%) and least likely from the West (7.1%), while low value centers were evenly distributed nationwide.

- 67 -

Conclusions: Value in pancreatic surgery does not require global excellence in all five quality indicators but can be achieved by superiority in a few indicators of quality while simultaneously and independently minimizing hospital charges.  

- 68 -

[27]are PatientS WitH biLateraL aDrenaL inciDentaLomaS

SimiLar to tHoSe WitH uniLateraL LeSionS?Authors: J. D. Pasternak1, C. Seib1, N. Seiser1, J. Tyrell1, C. Liu1, R. Cisco2,

J. Gosnell1, W. T. Shen1, I. Suh1, Q. Duh1

Institutions: 1University of California - San Francisco, 2 Good Samaritan HospitalPresenter: Jesse Pasternak

Discussant: Philip HaighCloser: Quan-Yang Duh

Importance: Adrenal incidentalomas are found in 1-5% of abdominal cross sectional imaging studies. Although the workup and management of unilateral lesions are well established, limited information exists for bilateral incidentalomas. Objective: To compare the natural history of patients with bilateral incidentalomas to those with unilateral incidentalomas. Design: Retrospective analysis of a prospective database of consecutive patients referred to an academic multidisciplinary adrenal tumor board.Setting: Tertiary care university hospital. Participants: A cohort of 500 patients between 2009 and 2014 referred for adrenal lesions.  Main Outcome Measures: Incidence, age, imaging characteristics, biochemical work-up, any intervention and final diagnosis. Results: Twenty-three patients with bilateral incidentalomas and 112 with unilateral incidentalomas were identified. The average age at diagnosis was 59 years old. Mean lesion size was 2.4cm on the right side and 2.8cm on the left. Bilateral incidentalomas were associated with a significantly higher incidence of subclinical Cushing’s syndrome (22% vs 6%, p=0.03), and a trend toward a lower incidence of pheochromocytoma (5% vs 19%, p=0.07) compared to unilateral lesions. Rates of hyperaldosteronism were similar in both groups (5%). Only 1 bilateral incidentaloma patient underwent unilateral resection. Mean follow-up was 4 years (range 1.2-13 years). There were no occult adrenocortical carcinomas. Conclusions: Bilateral incidentalomas are more likely to be associated with subclinical Cushing’s syndrome and less likely to be pheochromocytoma. Although patients with bilateral incidentalomas should be worked up in a similar manner to those with unilateral lesions, differences in their natural history warrant a greater index of suspicion for subclinical Cushing’s syndrome.

- 69 -

E-Poster Sessions A

- 70 -

Poster Session A: Moderators Farin Amersi and J. David Beatty

1a PERI-AREOLAR OR PERI-TUMORAL INJECTION OF ISOSULFAN BLUE AND THE EFFECT ON THE NUMBER OF SENTINEL LYMPH NODES EXAMINED IN BREAST CANCER Presenter: Joseph Weber

2a OMISSION OF SENTINEL NODE BIOPSY IN OLDER PATIENTS WITH EARLY STAGE INVASIVE BREAST CANCER Presenter: Alice Chung

3a INCREASING THE NUMBER OF NEGATIVE LYMPH NODES EXAMINED IN EARLY-STAGE BREAST CANCER PATIENTS WITH N1 DISEASE CORRELATES WITH IMPROVED SURVIVAL: ARE WE ADOPTING z11 TOO SOON? Presenter: Huan Yan

4a THE UTILITY OF BREAST SPECIFIC GAMMA IMAGING FOR INVASIVE LOBULAR CARCINOMA Presenter: Katherine Kelley

5a LONG-TERM OUTCOMES OF SCALP MELANOMA TREATED WITH EXCISION AND SENTINEL LYMPH NODE DISSECTION Presenter: Brian Parrett

6a EXTERNAL ILIAC SENTINEL NODES IN LOWER EXTREMITY MELANOMA ARE FREQUENT BUT RARELY IMPACT STAGING Presenter: Jennifer Tseng

7a UP-REGULATION OF CTLA-4 AND PD-1 GENE EXPRESSION IN SENTINEL NODES IS PREDICTIVE OF LYMPH NODE METASTASIS IN MELANOMA Presenter: David Kaufman

- 71 -

8a AGE-DEPENDENT EFFECTS OF RADIOTHERAPY IN PATIENTS WITH SOFT TISSUE SARCOMA UNDERGOING SURGERY Presenter: Noah Yuen

9a LONG TERM QUALITY OF LIFE FOLLOWING LAPAROSCOPIC BILATERAL ADRENALECTOMY FOR REFRACTORY CUSHING DISEASE Presenter: David Pham

10a LAPAROSCOPIC ANTRECTOMY AND OUTCOMES OF MULTIFOCAL GASTRIC CARCINOIDS WITH DIFFUSE NEURODENDOCRINE CELL HYPERPLASIA Presenter: Jenny Hong

11a SURGERY IN HIGH VOLUME HOSPITALS NOT COMMITTEE ON CANCER ACCREDITATION LEADS TO LONG-TERM CANCER SPECIFIC SURVIVAL FOR EARLY STAGE LUNG CANCER Presenter: Elizabeth David

12a THE SURVIVAL BENEFIT OF MEDIASTINAL LYMPH NODE DISSECTION FOR LUNG CANCER Presenter: Geena Wu

- 72 -

[1a]Peri-areoLar or Peri-tumoraL inJection oF

iSoSuLFan bLue anD tHe eFFect on tHe number OF SENTINEL LYMPH NODES EXAMINED IN

breaSt cancerAuthors: J. J. Weber, N. Vohra, J. H. Wong

Institution: East Carolina University Brody School of MedicinePresenter: Joseph Weber

Importance: The conduct of sentinel node biopsy (SLNBx) for breast cancer (BC) has evolved substantially since its original description. No national standards for the performance of SLNBx exist.Objective: We sought to determine the effect of isosulfan blue injection technique on nodal harvesting during SLNBx.Design: Retrospective cohort.Setting: An academic/community practice setting.Participants: SNBx BC patients who were pathologically staged as node negative.Main Outcome Measures: Number of SLNs examined following injection of filtered sulfur colloid intradermally and small volume isosulfan blue (ISB) injected either in the periareolar dermis (PA,~0.75cc) or large volume peri-tumoral (PT, 5cc).Results: Between January 1, 2009 and September 30, 2013, 1357 patients underwent SLNBx of which 966 (71.2%) were node negative. These patients range in age from 27-97yrs (mean 60.1 yrs). The majority of patients (76%) underwent PT injection of ISB. There was no significant difference in the mean age of these two groups (61.2 PT vs. 59.7 PA yrs). All were female. The majority of patients (72.7%) had T1 primaries. Nearly 73% of patients were Luminal A/B, 10.8% HER, and 16.4% were triple negative. There was no significant difference in the distribution of T stage (p=0.56) or BC subtypes between the techniques (p=0.59). The mean number of nodes examined was 3.1 (range 1-18). PT patients had a mean of 3.5 (range 1-18) nodes while PA patients had a mean of 2.4 nodes (range 1-10) (p<0.001). Conclusions: The technical aspects of injecting ISB effect the number of nodes harvested during SLNBx. It is unknown whether nodal staging accuracy or comorbidities are affected.

- 73 -

[2a]omiSSion oF SentineL noDe bioPSy in

oLDer PatientS WitH earLy Stage inVaSiVe breaSt cancer

Authors: A. P. Chung, A. Gangi, F. Amersi, X. zhang, A. Giuliano

Institution: Cedars-Sinai Medical CenterPresenter: Alice Chung

Importance: Sentinel node biopsy (SNB) in patients over age 70 with early stage breast cancer may not be necessary.Objective: Evaluate the incidence of loco-regional recurrence in patients age 70 or older with early stage invasive breast cancer who did not have SNB.Design: Review of a prospectively maintained database.Setting: Academic tertiary medical center with a designated breast center.Participants: One hundred and forty patients over age 70 with clinical T1-2N0 invasive breast cancer treated with breast conserving surgery (BCS) without axillary staging from January 1, 2000 through December 31, 2011. Main Outcome Measures: Loco-regional recurrence and breast cancer-specific survival.Results: Of 140 patients, median age was 83 (range 70-97 years). Tumors were more frequently T1 vs. T2 (74% vs. 26%, p<0.001), ER+ vs. ER- (86% vs. 14%, p<0.001), PR+ vs. PR- (73% vs. 27%, p<0.001), Her2- vs. Her2+ (92% vs. 8%, p<0.001) and of ductal histology vs. other (65% vs. 35%, p<0.001). More patients did not receive adjuvant chemotherapy, radiation or hormonal therapy compared to those who received adjuvant treatment (98% vs. 2%, p<0.001, 76% vs. 24%, p<0.001, 59% vs. 41%, p=0.04, respectively). With median follow up of 4.5 years, 5/140 patients (4%) experienced a breast cancer-related event: only one axillary recurrence was observed; and only 4 deaths from breast cancer were seen.conclusions: The incidence of loco-regional recurrence is low in patients over age 70 treated with BCS without axillary staging for early breast cancer and SNB may be safely omitted.

- 74 -

[3a]increaSing tHe number oF negatiVe LymPH noDeS EXAMINED IN EARLY-STAGE BREAST CANCER PATIENTS

WitH n1 DiSeaSe correLateS WitH imProVeD SURVIVAL: ARE WE ADOPTING Z11 TOO SOON?

Authors: H. Yan, D. M. Hari, N. Nassiri, C. Dauphine, B. E. Stabile, A. Kaji, J. Ozao-ChoyInstitution: Harbor-UCLA Medical Center

Presenter: Huan YanImportance: The role of axillary lymph node dissection in breast cancer is controversial and has been recently challenged.Objective: To determine if increasing the number of LNs examined (LNE) improves 10-year overall survival (OS) in early-stage breast cancer.Design: Retrospective study using the Surveillance, Epidemiology, and End Results database. Patients with T1 or T2 tumors (invasive ductal or lobular) treated between 1999 and 2001 were selected if they received partial mastectomy with adjuvant radiation and had 1-3 positive LNs, ≥ 1 LNE, and M0 disease.Setting: Nationwide database of cancer patients.Participants: 4,577 patients identified.Main Outcome Measures: Ten-year OS in relation to total number of LNE by univariate analysis and multivariate logistic regression.Results: Mean OS was 110.1 months (109.3-111.0). On multivariate analysis, factors associated with increased mortality were: negative HR status (p<0.001), higher grade (p<0.001), older age (p<0.001), T2 tumor (p<0.001), and number of positive LNs (p=0.022). On multivariate analysis, increasing total LNE was associated with decreased mortality (OR 0.989, p=0.042). When stratified by number of LNE, patients with >10 had significantly improved OS compared to those with 1-3 (table). Multivariable linear regression showed an OS benefit of 0.24 months for every additional LNE (p<0.001).

Conclusions: Increasing the number of negative LN examined correlates with improved survival in early-stage breast cancer patients with N1 disease. Further studies are needed to identify subsets of patients who would benefit most from complete lymph node dissection.

- 75 -

[4a]tHe utiLity oF breaSt SPeciFic gamma imaging For

inVaSiVe LobuLar carcinomaAuthors: K. A. Kelley1, J. Crawford1, K. Thomas2, S. Gardiner2, N. Johnson2

Institutions: 1Oregon Health and Science University, 2Legacy Good Samaritan Medical Center

Presenter: Katherine KelleyImportance: Functional breast tissue evaluation with breast-specific gamma imaging (BSGI) is sensitive and specific for the evaluation of additional disease in invasive ductal carcinoma (IDC) but not well known for ILC, which is difficult to detect even with adjunctive imaging.Objective: Evaluate the utility of BSGI as an adjunct in newly diagnosed ILC.Design, Setting, Participants: A retrospective review of a prospective imaging registry identified women undergoing BSGI for newly diagnosed breast cancer from 2006-2012. All women were surveyed using a Dilon 6800 gamma camera per Dilon Diagnostics protocol. Sensitivity and specificity were calculated and compared using McNemar’s test for paired proportions.Main Outcome Measures: Primary outcome was rate of detection of ILC, IDC and lesions not identified by standard mammography.Results: There were 699 women with invasive breast cancer; 44 ILC, 602 IDC, and 53 others (Table 1). The known lesion was detected in 80.7% of patients with IDC and in 86.4% of patients with ILC. Additional lesions were detected by BSGI in 34 IDC (5.6%) versus 7 of the ILC (15.9%) cancers. The sensitivity/specificity for ILC was 89/79% (p=0.2) compared to 85/82% (p=0.04) in IDC.Conclusions: We demonstrate that the detection of ILC and IDC is similar with BSGI. In addition, BSGI is a clinically useful adjunctive imaging modality as it improves detection of additional foci of disease in patients with ILC as compared to IDC. We therefore recommend BSGI for patients with ILC to ensure adequate staging and appropriate treatment.

- 76 -

[5a]Long-term outcomeS oF ScaLP meLanoma TREATED WITH EXCISION AND SENTINEL LYMPH

noDe DiSSectionAuthors: B. M. Parrett, S. Thummala, M. Kashani-Sabet,

M. I. Singer, S. P. Leong

Institution: California Pacific Medical Center

Presenter: Brian Parrett

Importance: Scalp melanoma has been observed to be aggressive with perhaps a distinct clinical behavior. Objective: To report the long-term outcomes of patients with scalp melanoma and compare outcomes to patients with other head and neck melanoma (HNM) locations. Design: Outcomes study utilizing a database review.Setting: Academic medical center.Participants: All patients who underwent excision and sentinel lymph node(SLN) dissection(SLND) for scalp melanoma from 1994 to 2009.Main Outcome Measures: SLN status, recurrence, false-negative SLN results, and survival. Scalp melanoma was compared to other HNM locations. Survival curves and multivariate analyses were performed.Results: Ninety-seven patients with scalp melanoma underwent excision and SLND. Median follow-up was 9 years. The scalp drained to a mean of 1.6 nodal basins; 16% drained to bilateral basins. The most common drainage was to the upper jugular and midjugular zones. The SLN was positive in 17.5% patients. Scalp melanoma patients had a significantly higher rate of false-negative SLN results compared to all other HNM sites (n=365, Figure 1). Scalp melanoma patients had a significantly increased mean tumor thickness (3.04mm vs. 2.13mm, P=0.0003) and a significantly increased risk of SLN-positivity and melanoma-specific 5-year mortality compared to all other HNM sites. Kaplan-Meier estimates showed that the risk for disease recurrence was substantially higher in scalp melanoma patients (P=0.0015) compared to all other HNM patients (Figure 2). 

- 77 -

Conclusions: Scalp melanoma patients present with thicker tumors with increased SLN-positivity, false-negative SLN results, and melanoma recurrence and, therefore, scalp melanoma represents a unique and aggressive category in HNM.

- 78 -

[6a]EXTERNAL ILIAC SENTINEL NODES IN LOWER

EXTREMITY MELANOMA ARE FREQUENT BUT RARELY imPact Staging

Authors: J. Tseng1, G. Jones1, J. Fortino1, J. T. Vetto1, 2

Institutions: 1Oregon Health and Science University, 2 Knight Cancer Institute

Presenter: Jennifer Tseng

Importance: The implications of drainage of cutaneous melanomas to external iliac (pelvic) nodes during sentinel node staging procedures is unknown.Objective: To determine the incidence, predictors, and clinical impact of external iliac (EI) sentinel nodes (SNs) in melanoma.Design: Retrospective review of prospectively collected data.Setting: Large cancer center.Participants: 979 clinically node negative melanomas staged by SN biopsy.Main Outcome Measures: Sites of primary tumors, corresponding SN drainage, positive SN rates, secondary procedures for positive SNs.Results: 62 melanomas (6.3%) in the entire data set drained to EI nodes, the majority (86%) from lower extremity primaries, and the rest from lower truncal primaries. EI drainage occurred in 25% (53/213) and 3% (9/328) of lower extremity and truncal melanomas, respectively. Drainage was isolated to EI nodes in only 16 (26%) of cases-most of the tumors drained to both EI and superficial groin (inguinal/femoral) nodes. The overall positive SN rate was 17% (similar to the rate for the entire database), but most positive nodes were in the superficial beds, and there were no cases of tumor isolated to EI SNs. EI SNs were positive in only 2 (3%) cases; in both, completion pelvic node dissections were negative for additional tumor.Conclusions: External iliac (pelvic) nodes are frequent sites of sentinel drainage in lower extremity melanomas, but are usually secondary, rarely positive, and not an isolated site of disease. These data support not removing external iliac sentinel nodes, especially when the primary drains to other nodal sites.

- 79 -

[7a]uP-reguLation oF ctLa-4 anD PD-1 gene

EXPRESSION IN SENTINEL NODES IS PREDICTIVE OF LymPH noDe metaStaSiS in meLanomaAuthors: D. z. Kaufman1, K. Gong2, E. Von Euw2, M. S. Sim2,

D. Slamon2, R. Essner1, 2

Institutions: 1Cedars-Sinai Medical Center, 2University of California-Los Angeles

Presenter: David Kaufman

Importance: The sentinel node (SN) has become the standard diagnostic tool for staging melanoma. With the recent development of several potent immunotherapies for advanced disease it may be important to understand the early immune events in the SN.Objective: To characterize the early immune-related events in the SN and relationship to lymph node tumor-positivity.Design: 81 sentinel nodes from 79 patients were evaluated with microar-ray technology, qPCR, and routine H&E and IHC. We identified 10 immuno-cytokines that are present by qPCR in SNs. Statistical analysis assessed the utility of these markers to predict tumor-positive SN. Setting: Tertiary surgical oncology centerParticipants: 79 patients underwent primary melanoma excision and SN biopsy. Main Outcome Measures: SN tumor statusResults: Of the 79 patients, 48 (61%) were men, and 31 (39%) were women. Median age was 59 (range 6-95 years). Primary melanomas were most commonly from the trunk (51%) and extremities (40%) and less commonly from the head and neck region (8%). The median thickness of the primaries was 0.95mm. 13% of the patients had ulcerated primaries. 29% of the primary tumors had at least 1 mitosis/mm2. 9 (11%) patients had SN metastasis, as determined by conventional H&E and IHC. The incidence of SN positivity was directly related to tumor thickness; the higher the T-stage the greater percentage of SN positivity: 2% T1, 19% T2, 20% T3, and 60% T4 melanoma. 33% of ulcerated primaries and 30% with increased mitotic rate had a tumor-positive SN. By univariate

- 80 -

analyses: age (p<0.001), primary site (<0.001), increasing gene expression of CTLA-4 (p<0.001) and PD-1 (p<0.001) were predictive of SN positivity. Multivariate analysis demonstrates mitoses in the primary and CTLA-4 and PD-1 gene expression in the SN were predictive of metastases in the SN. The up-regulation of CTLA-4 and PD-1 gene expression, in combination with increased mitosis was an accurate determinate of SN metastasis, as demonstrated by AUC values of 0.808 and 0.731 respectively.Conclusions: Up-regulation of CTLA-4 and PD-1 gene expression in SN is predictive of nodal metastasis in melanoma. The expression of these two genes in SN may be an early event in the immune response to melanoma metastases and a potential site for directing immunotherapy.

- 81 -

[8a]age-DePenDent eFFectS oF raDiotHeraPy

in PatientS WitH SoFt tiSSue Sarcoma unDergoing Surgery

Authors: N. K. Yuen, C. Li, A. Monjazeb, D. Borys, R. Bold, R. Canter

Institution: University of California - Davis

Presenter: Noah Yuen

Importance: Increasing evidence highlights the impact of inflammation and immune response on tumor response to radiotherapy (RT). These processes are known to wane with age.Objective: We hypothesized that the effects of RT in soft tissue sarcoma (STS) would be influenced by age, thereby affecting treatment outcome. Design: Using SEER (1990-2011), we identified 15,380 patients (>18) with non-metastatic STS undergoing surgery. We evaluated patient, tumor, and treatment variables by age, histology, and site. Main Outcome Measures: Multivariable Cox proportional hazards regression analyses were used to examine the effect of these variables on overall (OS) and disease-specific survival (DSS). Results: Mean age at diagnosis was 56.6, with 68% ≥ 65 years old. Leimoyosarcoma was the most common histology (30.1%), MFH (16.8%) and Sarcoma-NOS (10.8%). 59.9% of patients underwent surgery alone, 40.1% received adjuvant/neoadjuvant RT. Though most histologies demonstrated increased survival with RT, the greatest oncologic benefit occurred in patients ≥ 65: myxoid liposarcoma (OS-HR 0.50; p<0.01), rhabdomyosarcoma (OS-HR 0.23;p<0.01), epithelioid (OS-HR 0.01;p<0.01), sarcoma-NOS (OS-HR 0.66;p<0.01), leiomyosarcoma (OS-HR 0.84;p<0.04), and myxoid chondrosarcoma (OS-HR 0.02;p<0.04). Conversely, there was no difference in OS/DSS among patients < 65. Age-dependent oncologic benefits for patients ≥ 65 persisted when stratifying by tumor location, extremity (OS-HR 0.72; p<0.01) and viscera (OS-HR 0.78; p=0.01).Conclusions: Although RT was associated with superior oncologic outcome among STS patients undergoing surgery, these benefits were primarily observed in patients ≥ 65, independent of histology or tumor location. These data suggest age-dependent effects of RT in patients with STS.

- 82 -

[9a]Long term QuaLity oF LiFe FoLLoWing

LaParoScoPic biLateraL aDrenaLectomy For reFractory cuSHing DiSeaSe

Authors: D. V. Pham, J. F. Preston, D. Albright, R. Reidy, B. C. Sheppard, E. W. Gilbert

Institution: Oregon Health and Science UniversityPresenter: David Pham

Importance: Long-term data on quality of life (QOL) following laparoscopic bilateral adrenalectomy (BA) for Cushing disease (CD) is lacking.Objective: To determine the morbidity and long term QOL after BA for CD.Design: Retrospective review of patients that included a QOL phone survey (SF-12 with Cushing specific questions) from 1996-2010 who were treated for refractory CD with BA.Setting: Single institutionParticipants: Only patients with persistent CD after transsphenoidal pituitary tumor resection were included.Main Outcome Measures: Long term QOL including physical limitations and emotional well-being after BA.Results: 84 patients were identified with a median follow up of 5.5 years (1 month – 17.7 years). BA was completed laparoscopically in 82 patients (97.6%). Average age was 40 years and 90.5% were women. Nelson’s syndrome developed in 10.7% (9/84) of patients. Six (7.1%) patients died at a median of 7.7 (range 4-11) years after surgery. QOL surveys were completed in 35.7% (30/84) of patients, 7.1% did not respond, and 50% did not have current contact information. Six patients (20%) had no physical or emotional limitations, 17 (56.7%) had occasional limitations, and 7 (23.3%) were frequently limited.  All patients reported that these limitations were more manageable after surgery and 90% said that they would have surgery again if indicated.Conclusions: CD is associated with significant morbidity. Although patients continue to have limitations after BA, they are more subjectively manageable. Laparoscopic BA offers an acceptable treatment with favorable long term QOL for the management of refractory CD.

- 83 -

[10a]LaParoScoPic antrectomy anD outcomeS oF muLtiFocaL gaStric carcinoiDS WitH DiFFuSe

neuroenDocrine ceLL HyPerPLaSiaAuthors: J. Hong, E. Wolin, F. Amersi

Institution: Cedars-Sinai Medical CenterPresenter: Jenny Hong

Importance: Antrectomy for type 1 gastric carcinoids has been shown in a small study to lead to enterochromaffin-like cell (ECL) hyperplasia regression compared to Sandostatin or endoscopic resection. The clinical outcomes after laparoscopic antrectomy are not well knownObjective: To determine clinical and oncological outcomes for patients with multifocal type 1 gastric carcinoid with diffuse gastric neuroendocrine cell hyperplasiaDesign: Retrospective review of a prospectively maintained databaseSetting: Academic tertiary medical centerParticipants: Sixteen patients who underwent laparoscopic antrectomy between 2008 to 2014.Main Outcome Measures: Clinical outcomesResults: Median age was 60 years (range 45-72 years). Fourteen patients (88%) patients had tumors either in the body or in fundus. Median number of lesions was 2 (range 2-4). Only one complication with a negative re-operative laparoscopy for postoperative hematoma was observed. Five of 16 (31%) patients had mild reflux, which resolved with PPI’s. Gastrin and chromogranin A levels significantly decreased in all patients (97.8%, p=<0.001; 82.2%, p=0.004, respectively). Six of 10 (60%) patients who underwent gastric mapping after one year demonstrated ECL hyperplasia regression. All patients are alive and remain disease free at median follow-up of 3 years (range 0.5-5 years).Conclusions: This is the largest case series examining the clinical outcomes of laparoscopic antrectomy for multifocal type 1 gastric carcinoid. Our data suggest that this minimally invasive procedure is safe and results in regression of ECL hyperplasia. All patients had resolution of hypergastrinemia and no recurrence on follow-up gastric mapping. Yearly endoscopic and clinical surveillance of these patients is strongly recommended.

- 84 -

[11a]Surgery in HigH VoLume HoSPitaLS not

committee on cancer accreDitation LeaDS to Long-term cancer SPeciFic SurViVaL For earLy

Stage Lung cancerAuthors: E. A. David1, 2, Y. Chen1, R. Cress1, 4, R. J. Canter1, D. T. Cooke1

Institutions: 1University of California - Davis, 2David Grant Medical Center, 4Cancer Registry of Greater California

Presenter: Elizabeth David

Importance: Lobectomy with mediastinal lymphadenectomy is standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC). Objective:  Although previous studies show a relationship between hospital procedural volume and perioperative outcomes, we sought to evaluate the relationship of hospital volume on cancer-specific survival in early-stage NSCLC patients treated in California, as well as the influence on facility Committee on Cancer (CoC) accreditation long-term outcomes.Design: The California Cancer Registry was queried from 2004-2011 for cases of Stage I NSCLC and 8,435 patients were identified and stratified into groups by treatment with chemotherapy alone, radiation, or surgery. Statistical analysis was used to determine prognostic factors for overall survival. Hospitals were classified based on CoC accreditation and number of lobectomies and sublobar resections for Stage I NSCLC. Hospital volume was categorized as Low (<= 20), Medium (20-50), and High (>50). Results: 7,621 patients were treated with surgery and of these 76.9% were treated in a CoC accredited facility.  Distribution of surgical therapy by hospital volume was 57.8% (219/379) in low, 21.6% (82/379) in medium, and 20.6% (78/379) in high volume centers.  CoC accreditation was not significant for cancer-specific survival, but treatment in a high volume center was associated with longer survival when compared to low volume centers (HR 1.702, 1.419-2.041, p<0.0001) and medium volume centers (HR 1.215, 1.068-1.382,=0.003).

- 85 -

Conclusions: These data suggest that consideration of regionalization of the care of early-stage NSCLC patients may optimize long-term survival. 

- 86 -

[12a]tHe SurViVaL beneFit oF meDiaStinaL LymPH

noDe DiSSection For Lung cancerAuthors: G. Wu, R. Nelson, F. Grannis, D. Raz, J. Y. Kim

Institution: City of Hope National Medical Center

Presenter: Geena Wu

Importance: Pathologic lymph node staging is regarded important for prognosis and treatment determination in operable lung cancer. However, many patients do not undergo mediastinal lymph node dissection (MLND) and the impact of this for lung cancer survival by stage is unclear.Objective: Examine trends and compare survival between patients who had MLND and those who did not.Setting: The Surveillance Epidemiology and End Results (SEER) database was queried from 2003-2009. Participants: Surgical lung cancer patients with stage I-III non-small cell lung cancer that underwent pulmonary resection. Main Outcome Measures: Survival was compared between the two groups using Kaplan-Meier method. Stepwise regression analysis was used to identify independent predictors of survival.Results: There were 37,108 patients identified and 25,650 patients (69%) received MLND. Overall 5-year survival was 58% in those with, versus 55% in those without MLND (p < 0.0001). In addition, stage specific survival was also significantly better for patients with MLND versus those without: stage I 66% versus 63%, stage II 50% versus 42%, and stage III 39% versus 32% (p < 0.001 for all stages). In the multivariable model, MLND conferred a 14% reduction in mortality (hazard ratio, 0.86; 95% confidence interval 0.83-0.90; p<0.0001).Conclusions: Almost a third of patients undergoing pulmonary resection for lung cancer do not undergo MLND. MLND is associated with improved survival. The survival benefit is not just stage specific survival, but for combined stages as well, indicating the benefit is not simply due to stage migration.

- 87 -

E-Poster Sessions B

- 88 -

Poster Session B: Moderators Areti Tillou and Christian de Virgilio

1b 30-DAY OUTCOMES OF ELECTIVE AND EMERGENT PARAESOPHAGEAL HERNIA REPAIR: ANALYSIS OF 10,656 PATIENTS REPORTED IN THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM Presenter: Jennifer Kaplan

2b HYPONATREMIA IS ASSOCIATED WITH COMPLICATED APPENDICITIS Presenter: Dennis Kim

3b ANASTOMOTIC LEAK AFTER COLECTOMY: CURRENT RISK FACTORS, NATIONWIDE TRENDS IN MANAGEMENT AND OUTCOMES Presenter: Mark Hanna

4b ROBOTIC NOT LAPAROSCOPIC SURGERY ENABLED MINIMALLY INVASIVE TREATMENT OF RECTAL CANCER IN A VA MEDICAL CENTER Presenter: Eric Kubat

5b FACTORS ASSOCIATED WITH 30-DAY UNPLANNED SURGICAL READMISSION IN A CHILDREN’S HOSPITAL Presenter: Morgan Richards

6b CLINICAL COURSE AND RISK FACTORS FOR BILIARY COMPLICATIONS IN LIVER TRANSPLANT RECIPIENTS OF DONATION AFTER CARDIAC DEATH DONORS Presenter: Erik McDonald

7b THE IMPACT OF A POSITIVE DONOR MANAGEMENT GOAL BUNDLE STATUS CHANGE ON THE NUMBER OF ORGANS TRANSPLANTED PER DONOR AFTER NEUROLOGIC DETERMINATION OF DEATH Presenter: J. Salvador De La Cruz

8b GIANT HEMANGIOMAS- A 13-YEAR REVIEW AND THE NOVEL USE OF BLAND PRE-OPERATIVE EMBOLIzATION Presenter: Jennifer Pasko

- 89 -

9b THE CHANGING ROLE OF EXTRAANATOMIC BYPASS IN CONTEMPORARY VASCULAR SURGERY PRACTICE Presenter: Gregory Landry

10b LONG-TERM SURVIVAL AND FUNCTIONAL RESULTS FOLLOWING CAROTID ENDARTERECTOMY OR STENTING; ABSENCE OF SURVIVAL EFFECT DUE TO PREOPERATIVE SYMPTOMATOLOGY Presenter: Weldon Williamson

11b MATURATION RATES OF ONE-STAGE VERSUS TWO- STAGE BASILIC VEIN TRANSPOSITIONS Presenter: Christopher Yi

- 90 -

[1b]30-Day outcomeS oF eLectiVe anD emergent PARAESOPHAGEAL HERNIA REPAIR: ANALYSIS OF

10,656 PatientS rePorteD in tHe nationaL SurgicaL QuaLity imProVement Program

Authors: J. Kaplan, M. Lin, S. Rogers, S. Schecter, A. Posselt, J. CarterInstitution: University of California - San Francisco

Presenter: Jennifer KaplanImportance: The recommendation to observe or electively repair paraesophageal hernias (PEH) hinges upon accurate estimates of outcomes after elective or emergency surgery.Objective: To describe short-term outcomes of elective versus emergent PEH repair in the modern era and determine whether emergent repair is a predictor of mortality and serious complications.Design: Retrospective cohort study of PEH repairs reported to the National Surgical Quality Improvement Program (NSQIP) from 2005-2012.Setting: 315 U.S. hospitals participating in ACS NSQIP.Participants: Adults 18 years and older with diagnosis of PEH who underwent surgical repair.Main Outcome Measures: 30-day mortality and serious complications. Results: Of 10,656 patients, 383 (3.6%) underwent emergent PEH repair (42.5% laparoscopically) and 10,273 (96.4%) underwent elective repair (82.8% laparoscopically, p<0.001). 30-day mortality was 5.5% after emergent repair, but only 0.65% after elective repair (0.46% if laparoscopic), p<0.001. Serious complications occurred in 21% of emergency cases, compared to 5.2% of elective cases, p<0.001. Although patients who underwent emergent repair were older, more likely to be functionally dependent, less obese, and had more serious medicalco-morbidities; emergency repair remained an independent risk factor for death in multivariate analysis (odds ratio 3.2, p<0.001).Conclusions: Although emergent PEH repair was uncommon, the operation was more likely to be performed open, outcomes were poor, and emergency surgery was an independent risk factor for death. Conversely, outcomes of elective PEH repair were excellent, particularly when performed laparoscopically. Elective repair may be superior to watchful waiting for medically fit patients, even when symptoms are mild.

- 91 -

[2b]HyPonatremia iS aSSociateD WitH comPLicateD

aPPenDicitiSAuthors: D. Y. Kim1, N. Nariman1, C. de Virgilio1, M. Ferebee3, A. Kaji1,

C. Hamilton1, D. Plurad1, D. Saltzman3

Institutions: 1Harbor-UCLA Medical Center, 3Olive ViewPresenter: Dennis Kim

Importance: Hyponatremia is a commonly encountered metabolic abnormality among critically ill septic patients with necrotizing soft tissue infections and elderly patients with colonic perforation. The association between hyponatremia and complicated appendicitis among adult patients has not been previously investigated.Objective: To identify clinical variables associated with complicated appendicitis.Design: A 5-year retrospective cohort study.Setting: Two academic, university-affiliated County hospitals.Participants: Consecutive sample of 1,550 adult patients with acute appendicitis undergoing appendectomy.Main Outcome Measures: Intraoperative confirmation of perforated or gangrenous appendicitis.Results: Complicated appendicitis occurred in 26.4% of patients (n=409). These patients were older (P = .0002), with more comorbidities (P < .01), a longer duration of symptoms (48 vs. 24 hours, P < .0001), and more likely to present with electrolyte and acid-base abnormalities including hyponatremia (P < .0001). There was no difference in the time to operation between patients with and without complicated appendicitis (16 [10-21] vs. 16 [12-23] hours, P = .09). On Classification and Regression Tree and multiple logistic regression analyses, a serum sodium <135 mmol/L (OR=2.8, 95% CI=2.1-3.8; P < .0001) and duration of pain >48 hours (OR=2.7, 95% CI=2.1-3.6; P < .0001) were the strongest predictors of complicated appendicitis. Other independent predictors included polymorphonuclear leukocytes >85% (OR=2.3, 95% CI=1.8-3.0; P < .0001) and an admission heart rate >90 beats/minute (OR=2.2, 95% CI=1.7-2.9; P < .0001).Conclusions: The finding of hyponatremia among patients with acute appendicitis should alert surgeons to the potential for perforated or gangrenous appendicitis. Prospective validation of these findings is potentially warranted.

- 92 -

[3b]ANASTOMOTIC LEAK AFTER COLECTOMY:

current riSk FactorS, nationWiDe trenDS in management anD outcomeS

Authors: M. H. Hanna1, z. Moghadamyeghaneh1, G. S. Hwang3, S. D. Mills1, A. Pigazzi1, M. J. Stamos1, J. C. Carmichael1

Institutions: 1University of California - Irvine, 3University of Southern CaliforniaPresenter: Mark Hanna

Importance: Anastomotic leak (AL) after colectomy is a devastating complication and large-scale, population-based data regarding this event is lacking.Objective: Identify the incidence, risk factors and nationwide trends in management of AL after colectomy.Design, Setting and Participants: The ACS-NSQIP procedure-targeted database for Colectomy was used to retrospectively identify a large cohort of patients who underwent colectomy in 2012. Patients who developed postoperative AL were isolated and multivariate logistic regression analysis was used to identify leak predictors and management trends.Main Outcome Measures: Incidence, risk factors and management trends of AL post-colectomy.Results: 16,887 patients in the ACS-NSQIP database underwent colectomy in 2012. 3.6% (611) developed postoperative AL. Among patients with a leak: 56.6% were managed surgically, 24.7% with percutaneous intervention and 18.7% were managed with non-interventional, non-operative means. The mortality rate of patients with AL was higher than patients without (7.4% vs. 3.4%, AOR: 2.69, P<0.01). AL predictors included: diabetes (AOR: 1.47, P=0.04), smoking (AOR: 1.47, P=0.01), and disseminated cancer (AOR: 1.43, P=0.03). Multivariate analysis revealed that patients who underwent surgical treatment had a 4 day longer LOS compared to patients who were managed non-surgically (CI: 1-8 days, P<0.05). There was no significant difference in LOS between patients who underwent percutaneous intervention and non-interventional, non-operative management (CI: -0.79-14.26, P=0.07).

- 93 -

Conclusions: AL after colectomy has an incidence of 3.6% and is associated with a twofold increase in mortality.  Diabetes, smoking and disseminated cancer were the strongest risk factors for AL.  43.4% of AL patients were managed successfully via non-surgical means.

- 94 -

[4b]robotic not LaParoScoPic Surgery enabLeD

minimaLLy inVaSiVe treatment oF rectaL cancer in a Va meDicaL centerAuthors: E. Kubat1, S. Wren1, 2

Institutions: 1VA Palo Alto Healthcare Systems, 2Stanford UniversityPresenter: Eric Kubat

Importance: Minimally invasive surgery (MIS) for rectal cancer is technically demanding. Robotic surgery can facilitate the MIS approach to pelvic surgery.Objective: To evaluate a longitudinal experience in transition from open to robotic MIS rectal surgery.Design: Retrospective cohort Setting: Tertiary-care, VA Hospital Participants: Forty-eight patients (2006-2014) who underwent robotic (RRR), laparoscopic (LRR) or open (ORR) low anterior or abdominal-perineal rectal resections for cancer.Main Outcome Measures: Perioperative and oncologic outcomesResults: There were 14 ORR, 13 LRR and 21 RRR operations performed between 2006 and 2014. Neoadjuvant chemoradiation was administered in 75% (ORR), 46.2 % (LRR), and 71.4% (RRR) of cases. Median OR time was 396(ORR), 321(LRR), and 392(RRR) minutes. Estimated blood loss was highest in ORR (737ml) followed by LRR (379 ml) then RRR (186ml). Median hospital LOS was identical between LRR and RRR (10d) and increased in ORR (11.5 d). Conversion to open was 61% in LRR, in comparison to 4.7% in RRR. Median lymph node resection was 15(ORR), 16(LRR) and 17(RRR). No approach yielded a positive circumferential margin. With mean follow-up of ORR (35.7 months), LRR (35.6 months) and RRR (18.3 months) there were no local recurrences. However,n4 patients later developed metastatic disease (3-ORR; 1-LRR). By 2010 RRR became the procedure of choice and the subsequent 17/19 resections were done robotically. 30-day complications were highest in ORR (50%) and lowest in LRR (33%) and RRR (42%).Conclusions: Robotic surgery facilitated our transition of rectal cancer treatment to a minimally invasive approach. Conversion rates were low and locally advanced cancers were treated without compromising oncologic outcomes. The robotic approach was easily adopted and quickly replaced laparoscopy as an alternative to open surgery.

- 95 -

[5b]FactorS aSSociateD WitH 30-Day unPLanneD

SurgicaL reaDmiSSion in a cHiLDren’S HoSPitaLAuthors: M. Richards1, D. Yanez2, A. Goldin1, T. Grieb1,

W. Murphy1, G. Drugas1

institutions: 1Seattle Children’s Hospital, 2University of WashingtonPresenter: Morgan Richards

Importance: Unplanned readmissions within 30 days of discharge following operations are costly contributors to family dissatisfaction and are negatively associated with quality of care. Under the Affordable Care Act, Centers for Medicare & Medicaid Services will reduce payments to hospitals with excessive readmissions. This is the first single institution study to identify factors associated with unplanned readmission for pediatric surgical patients.Objective: To determine factors associated with pediatric readmission following surgical procedures.Design: Retrospective cohort study using internal administrative data and multivariable stepwise logistic regression.Setting: Freestanding children’s hospitalParticipants: All patients who underwent an inpatient operation from October 1, 2008-July 28, 2014.Main Outcome Measures: Factors associated with unplanned readmission within 30 days of discharge after operation (p<0.01).Results: Among 20,785 patients who underwent an operation there were 26,978 index encounters and 3,092 readmissions (10.5%). Fifteen of the candidate 25 variables considered in the stepwise regression were significantly associated with readmission. Patients requiring an emergency department visit within 365 days prior to operation, American Society of Anesthesiologists class ≥4, and patients discharged late in the day or on holidays were significantly more likely to have an unplanned readmission (RR 1.96; 95%CI 1.76-2.17, RR 2.06; 95%CI 1.64-2.60, RR 2.29; 95%CI 1.58-3.33, respectively). Moreover, readmission was associated with post-operative admitting service (RR 3.37; 95%CI 1.10-10.33, patients admitted to neonatology service).Conclusions: Patient and hospital factors are associated with readmission. Day and time of discharge represent variability of care and are important targets for hospital initiatives to decrease unplanned readmission.

- 96 -

[6b]cLinicaL courSe anD riSk FactorS For biLiary comPLicationS in LiVer tranSPLant reciPientS

oF Donation aFter carDiac DeatH DonorSAuthors: E. H. McDonald1, G. Veillette2, J. Parekh1, C. Freise1

Institutions: 1University of California - San Francisco, 2Westchester Medical Center

Presenter: Erik McDonald

Importance: Use of livers from donors after cardiac death (DCD) has been a useful strategy for increasing the donor supply for patients requiring liver transplantation, but there have been concerns regarding biliary strictures.Objective: To investigate outcomes of liver transplants using DCD grafts related to biliary strictures and characterize their impact on clinical course.Design: Retrospective cohortSetting: Academic centerParticipants: Liver transplant recipients between 2005 and 2012Exposure: Recipient of DCD liver allograftMain Outcome Measures: Incidence of biliary complications or death and the number and type of biliary interventions.Results: 37 subjects (27 men) (average age=54.7 years) underwent transplantation with a DCD graft. Average follow-up time was 2.4 years. The most common indication for transplant was HCV cirrhosis and seven patients died. Fifteen patients developed a stricture at the biliary anastomosis.nSubjects with strictures required an average of 4.7 (95%CI 2.9-6.4) interventions, typically ERCP. All but 3 patients had resolution of the stricture. No patient required re-transplantation for stricture. Donor age 29 years or older was associated with 3.7 (95%CI 1.2-11.0, p=0.006) times greater risk of developing a biliary stricture. Recipients of grafts from male donors had 0.38 (95%CI 0.17-0.83) times the risk of developing a stricture compared to female donors. Conclusions and Relevance: These results continue to support the use of DCD liver grafts; recipients and institutions need to be aware of the increased risk of biliary strictures and be prepared to treat them. Restricting donors to younger males may help reduce the rates of biliary strictures.

- 97 -

[7b]THE IMPACT OF A POSITIVE DONOR MANAGEMENT goaL bunDLe StatuS cHange on tHe number oF organS tranSPLanteD Per Donor aFter

neuroLogic Determination oF DeatHAuthors: J. S. De La Cruz1,2, M. B. Sally1,2, M. S. Patel3, M. Crutchfield1, K. Enestvedt1,2, D. Scott1,2, K. Roayaie1,2, S. Orloff1, 2, D. J. Malinoski1,2

Institutions: 1Portland Veteran Affairs Medical Center, 2Oregon Health and Science University,3Massachusetts General Hospital

Presenter: J Salvador De La Cruz

Importance: Meeting a bundle of critical care end points, or donor management goals (DMGs), is associated with more organs transplanted per donor (OTPD). It is unclear if this reflects the fact that younger/healthier donors are more likely to meet the DMG Bundle or whether active donor management and a positive change in Bundle Status from “not met” to “met” affects outcomes.Objective: To determine if a positive DMG Bundle Status change is associated with increased OTPDDesign: Prospective observational studySetting: Hospitalized careParticipants: Standard criteria donors after neurologic death managed by ten organ procurement organizations from 2012-2014Main Outcome Measures: DMGs represent normal cardiovascular, pulmonary, renal, and endocrine endpoints and were measured at two time points: (1) after authorization for donation and (2) prior to organ recovery.  DMG Bundle “met” was defined as achieving any seven of nine endpoints. A positive DMG Bundle Status change was defined as not meeting the Bundle at authorization and then achieving it prior to recovery.  The primary outcome measure was ≥4 OTPD.Results: 1398 donors had 3.7 ± 1.7 OTPD and 52% had ≥4 OTPD.  344 (25%) met the Bundle at authorization and 972 (70%) prior to recovery.  Of the 1054 not meeting the Bundle at authorization, 675 (64%) had a positive bundle status change and were more likely to have ≥4 OTPD (60% vs. 25%, p<0.001, Figure). After adjusting for known predictors, a positive Bundle Status change remained significant (Table).

- 98 -

Conclusions: A positive DMG Bundle Status change is associated with increased OTPD.

- 99 -

[8b]giant HemangiomaS- a 13-year reVieW anD

tHe noVeL uSe oF bLanD Pre-oPeratiVe EMBOLIZATION  

Authors: J. L. Pasko, K. G. Billingsley, C. K. Enestvedt, S. L. Orloff  

Institution: Oregon Health and Science University

Presenter: Jennifer Pasko

Importance: In patients with hemangiomas, surgical resection has the best long-term symptomatic relief. However, operative risks including intra-operative hemorrhage render justification of a surgical approach difficult for a benign disease.Objective: Examine 13-year operative outcomes of giant hemangiomas and assess impact of pre-operative bland embolization (PBE).Design: Retrospective reviewSetting: Tertiary university hospitalParticipants: Thirty patients with hemangioma size > 4 cm had operative intervention at this institution from 2001-2014. Five patients underwent PBE.  Main Outcome Measures: Estimated blood loss, intraoperative blood transfusion, length of stay (LOS), and complicationsResults: Tumor sizes ranged from 4–42 cm with mean of 13.8 cm (median 12 cm) for non-PBE hemangiomas with mean of 22.7 cm (median 20 cm) for PBE hemangiomas. Operations included lobectomies, segmentectomies, enucleation, and one transplantation. Blood transfusion was required in 8 of 30 patients; two were patients who received PBE. The Pringle maneuver was used in 9 of 29 patients; none was required for PBE patients. Post-operative LOS was 6.1 days for non- PBE and was 5.2 days for PBE patients. There were 5 complications all occurring in non-PBE patients. These included wound infection (3), DVT (1), and intra-operative death (1). Conclusions: PBE is a novel approach to surgical resection of giant hemangiomas by minimizing the need for both intra-operative blood transfusion and Pringle maneuver. No complications occurred in PBE group.   Future studies with larger cohort are needed to clarify differences that may be too subtle to determine based on small study size.

- 100 -

[9b]THE CHANGING ROLE OF EXTRAANATOMIC BYPASS IN

contemPorary VaScuLar Surgery PracticeAuthors: G. J. Landry, K. Perrone, T. Liem, E. Mitchell, A. Azarbal, G. Moneta

Institution: Oregon Health and Science UniversityPresenter: Gregory Landry

Importance: Extraanatomic bypass (EAB), including axillo (bi) femoral (AxF) and femoral-femoral (FF) bypass, has been supplanted by endovascular revascularization in modern practice. Its role and outcomes require redefinition.Objective: To determine the current role and outcomes of EAB.Design: Retrospective review of prospective operative database.Setting: Academic PracticeParticipants: All EAB at a single institution from 2006-2013.Main Outcome Measures: Patient demographics, indications, graft patency, limb salvage, and survival. Findings compared to prior published series from our institution predating aggressive endovascular management (1988-1993 and 1996-2001).Results:142 patients underwent EAB (59FF, 83AxF). Indications were chronic limb ischemia (n=67, 47%), acute limb ischemia (n=40,28%), graft infection (n=25,18%), and other (e.g., trauma, tumor resection) (n=10,7%). In comparison with previous series, procedures for chronic limb ischemia were significantly reduced (47% vs 78%, p< 0.001), with significant increase in procedures for acute limb ischemia (28% vs 14%,p=0.02) and comparable rate for infection (18% vs 12%,p=ns). Mean follow up was 13.3±20.2 months. Primary patency at 1,2 and 3 years for FF was 82%,75%, and 70% and for AxF 75%,68%,59% (p=ns), comparable to prior studies. Limb salvage at the same time points was 98%,91%,91% for FF and 88%,84%,77% for AxF (p=0.12), and survival was 76%,63%,60% for FF and 67%,54%,51% for AxF, also comparable to older studies. Patency, limb salvage and survival were similar for chronic limb ischemia and acute or infectious indications.Conclusions: EAB for chronic limb ischemia is in decline, likely due to increased endovascular interventions. It remains a vital treatment option for acute limb ischemia and infections. Graft patency, limb salvage, and survival remain unchanged despite the shift in indications.

- 101 -

[10b]Long-term SurViVaL anD FunctionaL reSuLtS

FoLLoWing carotiD enDarterectomy or Stenting; abSence oF SurViVaL eFFect Due to

PreoPeratiVe SymPtomatoLogyAuthors: W. K. Williamson, K. J. zerr, Y. Wu, A. P. Dunatchik,

C. J. Biemer, G. L. GrunkemeierInstitution: Providence St. Vincent Hospital and Medical Center

Presenter: Weldon Williamson

Importance: This information is critical in clarifying the importance of NASCET-defined symptomatology in determining treatment options.Objective: To document long-term survival and functional results of carotid endarterectomy (CAE) and carotid artery stent (CAS) patients.Design: Prospective enrollment and postoperative assessment of patients, with retrospective survival and functional follow-up.Setting: Vascular surgery service in a tertiary care hospitalParticipants: 1,459 patients who had CEA (N=1,338) or CAS (N=149) procedures performed during 2005-2012.Main Outcome Measures: Survival and SF36 functional scoresResults: Mean (maximum) follow up was 3.8 (9.6) years, total was 5,600 patient-years. Preoperative symptomatology (SX) was defined using NASCET criteria.nAfter adjusting for age, gender and SX, CAS had worse survival (p<0.001 by Cox regression), but SX was not significant (p=0.965). Survival was surprisingly similar for preoperatively asymptomatic (N=675) and symptomatic (N=663) CEA patients: 76.9% (95% confidence interval 78.0-80.2%) vs. 76.2% (72.2-79.7%), respectively, at 4 years and 48.4% (42.2-54.4%) vs. 48.2% (41.5-54.7%), respectively, at 8 years (see figure).For a subset of 250 patients who volunteered to supply SF-36 forms, at a mean follow-up of 5.0 years, physical function scores were 41.3 for both CEA (n=232) and CAS (n=20), and mental function scores were 51.9 for CEA and 47.5 for CAS. 

- 102 -

Conclusions: CEA had better long-term survival than CAS. Asymptomatic and symptomatic CEA patients had almost identical long-term survival. Further research is needed to clarify the importance of Asx/Sx findings in determining treatment options.

- 103 -

[11b]maturation rateS oF one-Stage VerSuS tWo-Stage baSiLic Vein tranSPoSitionS

Authors: C. E. Yi, A. Katz, V. L. Rowe, K. Woo

Institution: University of Southern California

Presenter: Christopher Yi

Importance: It is unclear if basilic vein transpositions (BVT) performed in a one-stage or two-stage approach is superior. Objective: Compare maturation rates of one-stage versus two-stage BVTs.Design: Retrospective reviewSetting: Tertiary care hospitalParticipants: Patients who underwent BVT between August 2009 and May 2014.Main Outcomes and Measures: For dialysis dependent patients, maturation was defined as the time when the fistula was used reliably for dialysis for two weeks. For pre-dialysis patients, maturation was defined as the time when the fistula was deemed mature on clinical exam.Results: 29 one-stage BVT (BVT1) and 33 two-stage (BVT2) were performed. Mean age in BVT1 was 53 vs 51 in BVT2 (P=NS). There were 15 (52%) males in BVT1 and 17 (52%) in BVT2 (P=NS). The smallest mean vein diameter by duplex in BVT1 was 3.3mm vs 2.9mm in BVT2 (P=NS).  There was no difference between the two groups in rates of steal, 30-day infection or requirement for adjunct procedures including fistulogram, angioplasty, percutaneous thrombectomy and open revision. There were 4 (14%) early thromboses in BVT versus 1 (3%) in BVT2 (P=0.12). Maturation rate for BVT1 was 62%, versus 91% for BVT2 (P = 0.007). The mean time to maturation was 60 days for BVT1 and 123 days for BVT2 (P<0.001). The time to mature for BVT2 included a mean of 80 days between stages.Conclusions: Two-stage BVTs have higher maturation rates. The delay between the first and second stages significantly increases the total maturation time for two-stage BVT. 

- 104 -

E-Poster Sessions C

- 105 -

Poster Session C: Moderators Linda Wong and Juan Carlos Jimenez

1c EPISODES OF HYPOTENSION ADVERSELY AFFECT SEPSIS-INDUCED CARDIAC DYSFUNCTION IN SEPTIC SHOCK Presenter: Samuel Schecter

2c WEIGHT A MINUTE: OBESITY NO LONGER PREDICTS DEATH FOLLOWING TRAUMA? Presenter: Rachael Callcut

3c FAILURE TO RESCUE IN THE ELDERLY: A SUPERIOR QUALITY METRIC FOR TRAUMA CENTERS Presenter: Galinos Barmparas

4c NEGATIVE ABDOMINAL CT FOR TRAUMA: NOW WHAT? Presenter: Elizabeth Benjamin

5c DECREASING CRANIAL COMPLICATIONS FOLLOWING DECOMPRESSIVE CRANIECTOMY FOLLOWING TRAUMA Presenter: Gail Tominaga

6c MISTREATMENT: THE PERSPECTIVE FROM SURGERY CLERKSHIP DIRECTORS Presenter: Cara Liebert

7c HAVING A FAMILY DURING SURGICAL RESIDENCY: IS IT POSSIBLE? Presenter: Cindy Kin

8c LAPAROSCOPIC SIMULATION FOR SURGICAL RESIDENTS: A KEY COMPONENT OF DEVELOPING LAPAROSCOPY IN UNDER-RESOURCED ENVIRONMENTS Presenter: Ellen Morrow

9c ARE U.S. SURGEONS AWARE THAT RACIAL DISPARITIES EXIST? THE HARD TRUTH Presenter: Breanne Britton

- 106 -

10c IS THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) SUPERIOR TO ADMINISTRATIVE DATABASES? A COMPARISON WITH THE NATIONWIDE INPATIENT SAMPLE Presenter: Anna Weiss

11c EFFECT OF OPERATING ROOM INEFFICIENCY ON HOSPITAL CHARGES FOR URGENT LAPAROSCOPIC CHOLECYSTECTOMY Presenter: Eric Campion

- 107 -

[1c]ePiSoDeS oF HyPotenSion aDVerSeLy aFFect SePSiS-

inDuceD carDiac DySFunction in SePtic SHockAuthors: S. C. Schecter1, N. Bir3, G. Victorino1, M. K. Bullard1, A. H. Harken1

Institutions: 1University of California - San Francisco, 3Woodland Health CarePresenter: Samuel Schecter

Importance: Systemic vasodilation during septic shock decreases both cerebral and myocardial perfusion. To maximize perfusion, Rivers et al and the Surviving Sepsis Campaign both target a mean arterial pressure  (MAP) of >65 mmHg. We hypothesized that episodes of hypotension adversely affect recovery from sepsis-induced-myocardial dysfunction.Objective: We aimed to determine whether pharmacological maintenance of MAP targets in septic shock preserves left ventricular function, as assessed by serial ultrasound determinations. Design: Retrospective reviewSetting: County hospitalParticipants: Between 2005 and 2010, we followed 105 patients who met criteria for septic shock requiring vasopressors to maintain MAPs >65 mmHg. Fifty-one patients had serial high quality ultrasound determinations of left ventricular ejection fraction.Main Outcome Measures: Changes in LVEF during and post-sepsis.Results: Of the 51 patients with cardiac ultrasounds during and post-recovery from septic shock, 12 patients had no change in LVEF; 20 patients had LVEF decrease ≥ 15%; and 19 patients had LVEF increase ≥ 15%. The twenty patients who suffered further depression in LVEF experienced 47 episodes of clinically documented hypotension (MAP < 65 mmHg).  The twelve patients in whom the sepsis-induced depression in LVEF did not change experienced nine episodes of hypotension.  The nineteen patients whose depressed LVEF recovered by at least 15% experienced no documented episodes of hypotension.Conclusions: We conclude that the maladaptive systemic vasodilation of septic shock should be treated aggressively to maintain a mean arterial blood pressure above 65 mmHg. The avoidance of episodes of hypotension may permit recovery of sepsis-induced left ventricular dysfunction.

- 108 -

[2c]WEIGHT A MINUTE: OBESITY NO LONGER PREDICTS

DeatH FoLLoWing trauma?Authors: R. Callcut, L. z. Kornblith, R. Kunitake, B. Redick, B. M. Howard, M.

F. Nelson, M. J. CohenInstitutions: University of California - San Francisco

Presenter: Rachael Callcut

Importance: Obesity has been shown to be a risk factor for mortality in studies pre-dating balanced resuscitation techniques. More recent retrospective studies have been inconsistent with some favoring no relationship.Objective: To investigate the impact of BMI on mortality following traumatic injuryDesign: Prospective cohort studySetting: Urban, Level 1 trauma centerParticipants: Sequential highest level adult trauma activationsMain Outcome Measures: Demographics, degree and duration of shock, major complications, and lab data.Results: Complete data was available on 770 patients and the median BMI was 26 (range 12.9 – 56.2). The median BMI of those who died was lower than survivors even when excluding underweight subjects (25 vs. 27, p=0.002).  Mortality in normal weight patients was 22%, overweight 20%, and obese 12% (p=0.007); however, the rate of head injury followed a similar pattern (normal weight 53% TBI vs. 45% overweight vs 36% obese, p=0.001). On univariate analysis, increasing BMI appeared have an inverse relationship to mortality with 20% lower odds of death per 5 unit increase in BMI (Table). However, this affect was negated on multivariate analysis once accounting for TBI, mechanism of injury, ISS, age, and sex (AUC 0.86, 0.83-0.89, p<0.0001).  Only age, ISS, and presence of a TBI remained predictive of mortality.

- 109 -

Conclusions: In the contemporary era of trauma care, obesity appears to have no effect on mortality following serious injury.  This finding may reflect improvements in care including benefits of hemostatic resuscitation and warrants further investigation.

- 110 -

[3c]FAILURE TO RESCUE IN THE ELDERLY: A SUPERIOR

QuaLity metric For trauma centerSAuthors: G. Barmparas1, M. J. Martin2, D. Weigmann3, K. R. Catchpole1,

E. J. Ley1, B. Gewertz1

Institutions: 1Cedars-Sinai Medical Center, 2Madigan Army Medical Center, 3University of Wisconsin

Presenter: Galinos Barmparas

Importance: Metrics are required to determine which trauma centers deliver superior care.Objective: We compared mortality after a reported complication, termed failure to rescue (FTR), and FTR in the elderly (FTRE) to determine which better identifies high risk trauma centers. We hypothesized that FTRE is a better indicator for high risk trauma centers compared to FTR.Design: Retrospective review of the National Trauma Databank (NTDB) research datasets 2010 and 2011.Setting: Trauma centers were classified as high risk if FTR and/or FTRE rate was greater than 15%.Participants: Patients ≥ 16 years admitted to trauma centers reporting ≥ 80% of AIS and/or ≥ 20% of comorbidities, with ≥ 200 subjects in the NTDB.Main Outcome Measures: Adjusted overall mortality after any trauma and after severe trauma (ISS ≥ 16).Results: Among the trauma centers, the mean mortality was 3.4 ± 1.2%; for elderly patients (> 65 y) it was 4.8 ± 2.2%. The mean FTR was 8.3 ± 6.7% and FTRE was 12.5 ± 9.5%. Admission to high risk trauma centers defined by increased FTR was not associated with a significantly higher risk for mortality after any trauma or after severe trauma (adjusted odds ratio [AOR] 1.06, p=0.09 and AOR 1.07, p=0.15 respectively). However, admission to high risk trauma centers defined by increased FTRE was associated with a significantly higher adjusted mortality after any trauma and after severe trauma (AOR 1.05; p=0.03 and 1.07, p=0.01 respectively).Conclusions: Due to the wide variation in patient injuries, trauma centers require reliable metrics to better compare the quality of care delivered. FTRE better predicts increased adjusted mortality than overall FTR.

- 111 -

[4c]NEGATIVE ABDOMINAL CT FOR TRAUMA:

noW WHat?Authors: E. Benjamin, S. Siboni, T. Haltmeier, A. Lofthus,

K. Inaba, D. Demetriades Institution: University of Southern California

Presenter: Elizabeth Benjamin

Importance: Liberal abdominal CT scan for trauma has become a common practice in many centers. However, its role in asymptomatic patients has been questioned because of the high incidence of negative result, concern about cost-effectiveness and risk of irradiation. One potential benefit of a negative study is early clearance for discharge or transfer to another service. It remains unclear, however, if it is safe to immediately discharge asymptomatic patients with negative imaging.Objective: Evaluate the role of further observation in the asymptomatic blunt trauma patient with negative CT imaging. Design: RetrospectiveSetting: Level I Trauma CenterParticipants: All patients that received a CT chest/abdomen/pelvis for blunt trauma in 2013 were reviewed. Patients with negative imaging formed the study group. Main Outcome Measures: Length of observation and delayed injury diagnosis.Results: During the study period, 620 patients had negative CT imaging and were admitted to the surgical observation unit. There were no delayed findings of missed intra-abdominal injury. Although 296 (48%) patients were discharged home within 24 hours, 324 (52%) remained >24hrs for orthopedic management (51%), comorbid conditions (21%), further imaging (18%), social reasons (6%), and wound care (3%). Three patients (1%) were held for continued abdominal pain and subsequently discharged without injury. Although abdominal pain was present on admission in 28% (n=171) and abdominal hematoma in 11% (n=71), no missed intra-abdominal injuries were identified after negative CT imaging.Conclusions: Asymptomatic, evaluable patients with a negative CT scan may be safely discharged from the ED, or dispositioned to another service.

- 112 -

[5c]DecreaSing craniaL comPLicationS FoLLoWing

DecomPreSSiVe craniectomy FoLLoWing traumaAuthors: G. T. Tominaga, F. K. Yoo, F. J. Coufal, I. S. Dandan,

K. B. Schaffer, A. B. EastmanInstitution: Scripps Memorial Hospital

Presenter: Gail TominagaImportance: Severe traumatic brain injuries are associated with high morbidity and mortality with or without surgical intervention.Objective: To review cranial complications (CC) following Decompressive Craniectomy (DC).Design: Retrospective.Setting: One Trauma Center with coverage by a single neurosurgical group.Participants: All trauma DC patients. Grp I=2005-June 2008; Grp II=2010-2013.Main Outcome Measures: CC, BF replacement (cranioplasty) and BF removal. Discharge home or Acute Rehab Hospital (ARH) were used as markers for functional recovery.Results: There were 58 DC patients; 29 pts in each group. There was no difference in age (33.6+17.8 vs 37.5+15.2 yrs) or initial GCS (7.6+4.3 vs 6.4+4.1) between Grp I and Grp II. Length of stay was longer (46.1+39.3 vs 24.0+43.3 days, p=0.0466) and BF replacement time was shorter (79.8 vs 120.7days, p<0.0001) in Grp I vs Grp II.Table. Outcome Measures by Group.

In Grp I, 4 of 7 cranioplasties performed during initial hospitalization required BF removal. Patients were discharged home or ARH in 17 patients (59%) in Grp I and 13 patients (45%) in Grp II.Conclusions: Cranial complications following DC are common. We demonstrated a decreasing trend in CC with meticulous wound care and by not performing cranioplasty during the initial hospitalization. Additional studies are warranted to determine optimal timing of BF replacement.

Grp Total # pts with CC

Post-op Hydro-cephalus

Wound infection or dehiscence

CSF leak or pseu-domen-ingoceal

Superior Sagittal Sinus Thrombosis

Brain abscess

Brain infarct

BF replaced

BF removal

Mortality

1 11 8 9 10 2 3 0 12 4 9 (31%)

11 7 6 3 4 0 1 1 9 1 11 (38%)

- 113 -

[6c]MISTREATMENT: THE PERSPECTIVE FROM SURGERY

cLerkSHiP DirectorSAuthors: C. A. Liebert1, M. E. Brunsvold4, A. L. Winthrop5, S. Holmquist6, J. N. Lau1

Institutions: 1Stanford University, 4University of Minnesota, 5Queen’s University, 6University of Chicago

Presenter: Cara LiebertImportance: Mistreatment is pervasive, with 42.1% of medical students reporting mistreatment on the 2013 AAMC graduation questionnaire. Mistreatment rates on surgery clerkships and prevalence of interventions to reduce mistreatment are largely unknown.Objective: To characterize reported student mistreatment in surgery clerkships and prevalence of educational programs aimed at reducing mistreatment.Design: Multi-institutional cross-sectional online survey.Setting: Surgery clerkship directors (n=141) were invited in April 2014 to participate in an anonymous online survey regarding student mistreatment.Participants: Forty-two clerkship directors completed the survey.Main Outcome Measures: Rates and types of reported mistreatment; existing interventions to address mistreatment; qualitative analysis of open-ended responses to identify major themes.Results: In the past year, surgery clerkship directors received reports of experienced mistreatment from 2.1% of students (range 0%-10.3%). The most frequent types were classified as power and verbal mistreatment. Consequences were that of informal investigation, counseling, and escalation. Although 91% of respondents reported educational programs on mistreatment at their institution, only 61% reported efforts to address mistreatment by their department. Institutional educational interventions included Grand Rounds sessions, discussion of mistreatment policies at annual intern orientation, and student orientation prior to third year clerkships. Department-initiated interventions consisted of annual lectures for faculty and residents, while students received discussion of policies and procedures during clerkship orientations.Conclusions: This multi-institutional survey study further identifies rates and types of reported mistreatment in surgery core clerkships. Despite the importance of this topic, 39% of surgery clerkship directors reported no existing departmental interventions to address student mistreatment.

- 114 -

[7c]HAVING A FAMILY DURING SURGICAL RESIDENCY:

IS IT POSSIBLE? Authors: C. Kin, M. Welton, C. Mueller

Institution: Stanford UniversityPresenter: Cindy Kin

Importance: Having a family during residency is increasingly common. The balance of work and family presents a challenge for trainees and residency programs. It is important to understand these challenges to optimize training, set expectations, and minimize attrition. Objective: To determine if surgical trainees differ from medical trainees in their decisions to have children.Design: An anonymous online survey was administered. Respondents received a $10 gift certificate.Setting: Academic medical institution. Participants: The survey was sent to all 776 housestaff. Of the 452 residents who started the survey, 435 completed it; 98 were surgical residents.Main Outcome Measures: The difference in the proportion of medical and surgical trainees who have children during residency. Results: The proportion of residents with children in surgical vs medical training programs was comparable (22.4% vs 24.6%, p=NS). The majority of childless residents were deferring having children because of their jobs (67% of surgeons, 58% of nonsurgeons, p=NS), but surgical residents were more likely to believe that having children during residency would negatively affect their professional reputation (33% vs 18%, p=0.02) and make them a burden on their colleagues due to family leave (65% vs 45%, p=0.006). Surgical residents were more likely to work >70 hours/week (94% vs 33%, p<0.001). More nonsurgical residents agree that their programs are supportive of residents with children (77% vs 56%, p=0.002).Conclusions: Residency training plays a major role in trainees’ decisions to have families. Surgical residents face different challenges than their medical colleagues due to differences in culture and workload.

- 115 -

[8c]LAPAROSCOPIC SIMULATION FOR SURGICAL RESIDENTS: a key comPonent oF DeVeLoPing LaParoScoPy in

unDer-reSourceD enVironmentSAuthors: H. Morrow1, A. Bekele2, A. Tegegne2, B. Kotisso2, E. Warner1,

J. Kaufman4, A. A. Oelschlager1, B. Oelschlager1

Institutions: 1University of Washington, 2Addis Ababa University, 4Puget Sound Surgical Center

Presenter: Ellen Morrow

Importance: Laparoscopic procedures are infrequently available in under-resourced areas, in part due to lack of expertise.Objective: To develop and implement a laparoscopic skills curriculum in an Ethiopian surgical residency program. We hypothesized that residents would improve their laparoscopic skills, thereby facilitating the integration of laparoscopy into the clinical arena.Design: A laparoscopic curriculum was developed using existing models that were adapted for this environment.  Each course included one day of didactics and skills lab practicum, followed by a day of operating room observation. Setting: Six courses were conducted during 2012 and 2013 in a teaching hospital in Ethiopia.Participants: Eighty-eight surgical residents participated. Main Outcome Measures: Lab task completion times, student survey responses, and laparoscopic case volume.Results: Students showed significant improvement in time to complete skills tasks with practice (see table). All Twenty-two participants who were surveyed reported that the course was valuable, and they would recommend it. The curriculum is now taught and sustained by local faculty.  The rate of laparoscopic cholecystectomy went from less than 1 case per month to 4 cases per week.

- 116 -

Conclusions: The development and implementation of a collaborative and sustainable laparoscopic curriculum is possible in a low resource environment.  Such a curriculum can result in improved laparoscopic expertise, surgical trainee satisfaction, and facilitate the development of a clinical laparoscopic program.

- 117 -

[9c]are u.S. SurgeonS aWare tHat

RACIAL DISPARITIES EXIST? tHe HarD trutH

Authors: B. Britton1, N. Nagarajan1, S. Selvarajah1, A. Schupper1, A. Salim2, A. Haider1

Institutions: 1The Johns Hopkins University School of Medicine, 2Brigham and Women’s Hospital

Presenter: Breanne Britton

Importance: Across the field of surgery, blacks have higher rates of hospital complications, disease recurrence, and mortality. Though these disparities are extensively documented in the literature, anecdotal evidence suggests surgeons are still unaware of these inequities.Objective: To measure US surgeons’ awareness of racial disparities in surgical care and outcomesDesign: A 21-question online survey administered between 07/2013 and 03/2014. The survey was validated using cognitive interviews and pretests.Setting: Cross sectional survey of surgeons Participants: A computer-generated random sample of US Fellows of the American College of SurgeonsMain Outcome Measures: Proportion of surgeons who report awareness of racial disparities in surgical care and outcomesResults: Of the 536 surgeons invited to participate, 172 (32%) completed the survey. Respondent demographics included: 68.6% male, 75.0% white, 64.0% urban, and 79.7% associated with an academic medical center (AMC). Only 35.5% of surgeons agreed racial disparities exist in healthcare in general, and only 11.1% thought racial disparities are present at their hospital or clinic. 4.7% reported racial disparities exist in their practice. After adjusting for sex, race, AMC affiliation, practice setting, and medical school graduation year, surgeons who believed the literature supporting the existence of racial disparities to be weak were significantly less likely to report disparities in healthcare, their organization, and their practice (table).

- 118 -

Conclusions: Awareness of racial disparities is low amongst surgeons, especially in regards to their own practice. Surgeons are less likely to recognize racial disparities if they do not believe the literature on racial disparities is strong.

Table: Association between perceived strength of the literature on racial disparities and reporting awareness of disparities

Odds

Ratio1

95% CI

Reporting awareness of disparities in healthcare

0.190.08-0.41

Reporting awareness of disparities in own hospital or clinic

0.060.01-0.32

Reporting awareness of disparities in own practice

0.070.01-0.71

1 Odds of reporting awareness of racial disparities if one perceives the literature on racial disparities to be weak vs reporting awareness of disparities if one perceives the literature to be strong.

- 119 -

[10c]iS tHe nationaL SurgicaL QuaLity imProVement

PROGRAM (NSQIP) SUPERIOR TO ADMINISTRATIVE DatabaSeS? a comPariSon WitH tHe nationWiDe

inPatient SamPLeAuthors: A. Weiss1, J. A. Anderson3, D. C. Chang2

Institutions: 1University of California - San Diego, 2Massachusetts General Hospital, 3University of California - Davis

Presenter: Anna WeissImportance: The National Surgical Quality Improvement Program (NSQIP) is widely heralded as the most robust database for evaluating surgical outcomes. However, evidence of NSQIP superiority remains unproven.Objective: To determine if NSQIP is a more robust database than Nationwide Inpatient Sample (NIS).Design: The area under the receiver operator characteristic (ROC) curve was compared between multivariate logistic regressions predicting inpatient mor-tality and complications in each database.Setting: NSQIP and NIS databases from 2010Participants: All patients with the following procedures were included: abdominal aortic aneurysm repair, appendectomy, aortic valve replacement, coronary artery bypass graft, carotid endarterectomy, laparoscopic cholecystectomy, total and partial colectomy, esophagectomy, sleeve gastrectomy, pancreatectomy, and ventral hernia repair.Main Outcome Measures: The ROC curves were measured; a higher area under the ROC curve represents a more robust, accurate multivariate analysis.Results: The area under the ROC curve was consistently higher in predicting complications and mortality in NSQIP versus NIS except for sleeve gastrec-tomy. The areas under the ROC curves for death are the following: abdominal aortic aneurysm repair is 0.9 in NSQIP versus 0.64 in NIS; 1 versus 0.91 for appendectomy, 0.98 versus 0.64 aortic valve, 1 versus 0.68 coronary bypass, 0.86 versus 0.71 carotid endarterectomy, 0.97 versus 0.83 cholecystectomy, 0.93 versus 0.68 colectomy, 0.93 versus 0.64 esophagectomy, 0.74 versus 0.66 pancreatectomy, and 0.93 versus 0.74 ventral hernia.Conclusions: The depth of preoperative risk variables collected by NSQIP allows for a more robust risk-adjusted analysis compared to NIS. Wider participation in NSQIP could allow more hospitals to participate in robust surgical outcomes and quality research.

- 120 -

[11c]eFFect oF oPerating room ineFFiciency on

HOSPITAL CHARGES FOR URGENT LAPAROSCOPIC cHoLecyStectomy

Authors: E. M. Campion1, A. R. Privette2, L. z. Kornblith1, B. Redick1, B. M. Howard1, J. M. Crane1, J. Moyer1, A. Evans1, M. J. Cohen1, R. A. Callcut1

Institutions: 1University of California - San Francisco, 2Medical University of South Carolina

Presenter: Eric CampionImportance: Acute gallbladder conditions are one of the most common indications for surgical admission requiring operation. In safety net hospi-tals, operating room (OR) availability can be significantly delayed.Objective: We hypothesized that the delay in OR access (DTOR) for patients with acute gallbladder disease results in poor resource usage, worsened outcomes and significant increases in hospital charges.Design: Demographics, operative booking forms, operative length, complications, conversion to open, and charges were reviewed for patients receiving laparoscopic cholecystectomy after urgent admission in 2011. Multiple regression was utilized to determine charge per hour for those booked for the OR on the day of admission. Outcomes were analyzed for relationship to DTOR and complication charges were determined in multiple regression.Main Outcome Measure(s): The effect of DTOR on hospital charges.Results: There were 99 laparoscopic cholecystectomies for acute cholecystitis(AC)(n=73), biliary colic/choledocholithiasis(n=11), and gallstone pancreatitis(n=14). Overall complication rate 11.5%. For AC patients, the conversion to open (CTO) rate was 15.6%. In multiple regressions controlled for CTO, the charge for a laparoscopic cholecystectomy done for AC was $39,668. Each additional hour of delay added $579($227-$932, p=0.002) in charges or $13,903 per day. There was no correlation between DTOR and complications or operative length (p=NS). For patients with any complication, an additional $35,046 in additional charges was accumulated. If wait times at our institution improved to 8 hours, it would save $1.73 million per 100 casesConclusions: DTOR represents a significant contributor to increased hos-pital charges. OR efficiency represents an opportunity for significant cost savings to the health care system.

- 121 -

- 122 -

Harold Brunn Frank Hinman Emmet Rixford

Thomas O Burger W. D. Kirkpatrick Samuel Robinson

Samuel H. Buteau Otis F. Lamson Paul Rockey

S. L. Caldbick A. Stewart Lobinger Henry Sherk

Robert C. Coffey Charles D. Lockwood Ernst A. Sommer

Walter B. Coffey A.O. Lee Stanley Stillman

John F. Cowan J. Tate Mason Charles T. Sturgeon

Richard B. Dillehunt A. Aldridge Matthews George W. Swift

Sumner Everingham J. B. McNerthney Wallace G. Toland

Charles Fox Wayland A. Morrison Alanson Weeks

Edgar L. Gilcrest Howard C. Naffziger Horace G. Wethrill

Philip K. Gilman Charles E. Phillips

PCSA Founders

- 123 -

PcSa Past Presidentspresident Elected

Year Location Meeting Year caucus

Fred Weaver 2013 Dana Point, CA 2014 SCMika Sinanan 2012 Kauai, HI 2013 WA/BC/AKJames Holcroft 2011 Napa Valley, CA 2012 NCJames Atkinson 2010 Scottsdale, Az 2011 SCJames J. Peck 2009 Maui, HI 2010 HA/OROrlo Clark 2008 San Francisco, CA 2009 NCBruce Stabile 2007 San Diego, CA 2008 SCMichael J. Hart 2006 Kohala Coast, HI 2007 AK/BC/WACornelius Olcott IV 2005 San Francisco, CA 2006 NC

Samuel Eric Wilson 2004 Laguna Nigel/Dana Point, CA 2005 SC

Livingston Wong 2003 Wailea, HI 2004 HA/ORThomas R. Russell 2002 Monterey, CA 2003 NCTheodore X. O’Connell 2001 Las Vegas, NV 2002 SCJohn K. MacFarlane 2000 Banff, AB 2001 AK/BC/WARobert C. Lim, Jr. 1999 San Francisco, CA 2000 NCThomas V. Berne 1998 San Jose del Cabo, Baja 1999 SCR. Mark Vetto 1997 Kaanapali Beach, HI 1998 HA/ORF. William Heer 1996 Napa Valley, CA 1997 NCRonald K. Tompkins 1995 San Diego, CA 1996 SCMeredith P. Smith 1994 Seattle, WA 1995 AK/BC/WANorman M. Christensen 1993 Sacramento, CA 1994 NCLouis L. Smith 1992 Scottsdale, Az 1993 SC

Clare G. Peterson 1991 Keoneloa Bay at Poipu, Kauai, HI 1992 HA/OR

Allen H. Johnson 1990 Pebble Beach 1991 NCEric W. Fonkalsrud 1989 Laguna Nigel, CA 1990 SCGeorge I. Thomas 1988 Vancouver, BC 1989 AK/BC/WAJohn K. Stevenson 1988 Vancouver, BC 1989 AK/BC/WAF. William Blaisdell 1987 San Francisco, CA 1988 NCJohn E. Connolly 1986 Rancho Mirage, CA 1987 SC

- 124 -

president Elected Year Location Meeting

Year caucus

Thomas J. Whelan, Jr. 1985 Maui, HI 1986 HA/ORRoy Cohn 1984 Monterey, CA 1985 NCWiley F. Baker 1983 Newport Beach, CA 1984 SCHilding H. Olson 1982 Seattle, WA 1983 AK/BC/WADavid J. Dugan 1981 Napa Valley, CA 1982 NCWilliam R. Mikkelsen 1980 Coronado, CA 1981 SCThomas R. Montgomery 1979 Hawaii 1980 HA/ORPhilip R. Westdahl 1978 Yosemite, CA 1979 NCWilliam F. Pollock 1977 Newport Beach, CA 1978 SCCarl R. Schlicke 1976 Palm Springs, CA 1977 AK/BC/WARalph D. Cressman 1975 Monterey, CA 1976 NCMax R. Gaspar 1974 Scottsdale, Az 1975 SCAllen M. Boyden 1973 Kaanapali Beach, HI 1974 HA/ORPaul C. Samson 1972 Yosemite, CA 1973 NCGordon K. Smith 1971 San Diego, CA 1972 SCJoel W. Baker 1970 Mexico City, Mexico 1971 AK/BC/WAH. Brodie Stephens 1969 San Francisco, CA 1970 NCLyman A. Brewer III 1968 Palm Springs, CA 1969 SCMatthew McKirdie 1967 Honolulu, HI 1968 HA/ORLeon Goldman 1966 Monterey, CA 1967 NCArthur Pattison 1965 Palm Springs, CA 1966 SCRalph H. Loe 1964 Vancouver, BC 1965 AK/BC/WACarleton Mathewson, Jr. 1963 San Francisco, CA 1964 NCJohn C. Jones 1962 Palm Springs, CA 1963 SCJohn E. Raaf 1961 Portland, OR 1962 HA/ORRobert A. Scarborough 1960 San Francisco, CA 1961 NCClarence J. Berne 1959 Palm Springs, CA 1960 SCCaleb S. Stone, Jr. 1958 Victoria, BC 1959 AK/BC/WAH. Glenn Bell 1957 Santa Barbara, CA 1958 NCWilliam J. Norris 1956 Palm Springs, CA 1957 SCLouis R. Gambee 1955 Palm Springs, CA 1956 HA/ORLoren R. Chandler 1954 Yosemite, CA 1955 NC

- 125 -

president Elected Year Location Meeting

Year caucus

E. Eric Larson 1953 Santa Barbara, CA 1954 SCAlexander B. Hepler 1952 Harrison Hot Springs, BC 1953 AK/BC/WAAlson R. Kilgore 1951 Del Monte, CA 1952 NCWilliam K. Kroger 1950 Coronado, CA 1951 SCEugene W. Rockey 1949 Gearhart, OR 1950 HA/ORHoward C. Naffziger 1948 San Francisco, CA 1949 NCLeroy B. Sherry 1947 Los Angeles, CA 1948 SCHomer D. Dudley 1946 Victoria, BC 1947 AK/BC/WAPhilip K. Gilman 1945 San Francisco, CA 1946 NCPhilip K. Gilman 1944 No meeting due to WWII 1945 NCPhilip K. Gilman 1943 No meeting due to WWII 1944 NCPhilip K. Gilman 1942 No meeting due to WWII 1943 NCPhilip K. Gilman 1941 No meeting due to WWII 1942 NCCharles T. Sturgeon 1940 Los Angeles, CA 1941 SCRichard B. Dillehunt 1939 Pointland, OR 1940 HA/ORSumner Everginham 1938 Del Monte, CA 1939 NCWayland A. Morrison 1937 Los Angeles, CA 1938 SCOtis F. Lamson 1936 Vancouver, BC 1937 AK/BC/WAHarold Brunn 1935 Del Monte, CA 1936 NCE. C. Moore 1934 Santa Barbara, CA 1935 SCErnst A. Sommer 1933 Gearhart, OR 1934 HA/OREmmet Rixford 1932 Del Monte, CA 1933 NCRea Smith 1931 Santa Barbara, CA 1932 SCJ. Tate Mason 1930 Victoria, BC 1931Wallace I. Terry 1929 Del Monte, CA 1930 NC

A. Stewart Lobinger 1928 No info available 1929 No info available

Robert C. Coffey 1927 No info available 1928 No info available

Stanley Stillman 1926 No info available 1927 No info available

Charles D. Lockwood 1925 Del Monte, CA 1926 NCFounder’s Meeting San Francisco, CA 1925

- 126 -

PCSA New Membersclass of 2015

Peyman benHaraSH, mDSpouse/Partner: Belinda Ko MDChildren: Hannah and Noah Caucus: Southern CaliforniaSpecialty: Cardiothoracic SurgeryPosition/Location: Assistant Professor of Surgery, UCLA David Geffen School of Medicine, Director of Cardiovascular Simulation, UCLA, Los Angeles, CaliforniaSurgical interests: Cardiovascular simulations, cardiac arrhythmias and neuronal mechanisms, cardiac tissue engineeringSponsors: Jonathan Hiatt, Bruce Stabile, Christian de Virgilio

racHaeL caLLcut, mDSpouse/Partner: Matthew Mell, MDChildren: Andrew & SamCaucus: Northern CaliforniaSpecialty: Trauma/Critical/General SurgeryPosition/Location: Assistant Professor of Surgery, UCSF, San Francisco, CaliforniaHobbies: Spending time with my dogs, wine collecting, travel, college sports, Giants baseball & fashionSponsors: Jan Horn, Rochelle Dicker, William Schecter, Margaret Knudson

- 127 -

WaLDo concePcion, mDSpouse/Partner: Rosie SalcedoChildren: Christine (25) Katherine (23) zoe (13)Caucus: Northern CaliforniaSpecialty: Transplantation SurgeryPosition/Location: Professor of Surgery, Stanford University Medical Center, Stanford, CaliforniaInterests: Tennis, traveling, classical music, playing trumpet and violin, healthcare policy, surgical outcomes in transplantation, historian, qualitySponsors: Carlos Esquivel, Mark Melcher, Clark Andrew Bonham

mark FarieS, mDSpouse/Partner: NicoleChildren: Nicholas, Anna, JamesCaucus: Southern CaliforniaSpecialty: Surgical OncologyPosition/Location: Professor of Surgery, John Wayne Cancer Institute, Director, Melanoma Research, JWCI, Santa Monica, CaliforniaHobbies: Children’s sports, childrens’ music, childrens’ scouting, photography, canoeingSponsors: Anton Bilchik, Andrew DiFronzo, Donald Morton

arVin gee, mDSpouse/Partner: Sherilyn TeeterChildren: Jillian & VivianCaucus: Oregon/HawaiiSpecialty: General SurgeryPosition/Location: Attending Trauma/Critical Care/General Surgeon, Legacy Emanuel Medical Center, Portland, OregonHobbies: Photography, hiking, cookingSponsors: Karen Deveney, William Long, Richard Mullins

- 128 -

JeSSica goSneLL, mDSpouse/Partner: Bob Savio, MDChildren: Jackson, Gabriel, OlympiaCaucus: Northern CaliforniaSpecialty: Endocrine SurgeryPosition/Location: University of California, San Francisco, CaliforniaHobbies: Literature, soccer, writing, bakingSponsors: Quan-Yang Duh, Orlo Clark, Wen Shen

Scott HanSen, mDSpouse/Partner: Christyna HartwickChildren: Chase (15), Lane (12), Madison (2)Caucus: Northern CaliforniaSpecialty: Plastic, Reconstructive and Hand SurgeryPosition/Location: Associate Professor of Surgery, University of California, San FranciscoHobbies: Baseball with kids, travelSurgical interests: Reconstructive microsurgery, hand surgerySponsors: William Schecter, Mary McGrath, Hobart Harris, Rochelle Dicker

aVitaL Harari, mDSpouse/Partner: Ron TzadikChildren: Aviv Eliam (3 mths)Caucus: Southern CaliforniaSpecialty: Endocrine SurgeryPosition/Location: Assistant Professor of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CaliforniaHobbies: Traveling all over the world (have been to >40 countries), painting, hiking, lounging on the beach, scuba diving, art, museums, opera, symphony, theatreSurgical interests: Multidisciplinary management of benign and malignant tumors of the adrenal, thyroid, and parathyroid glands as well as the neuroendocrine pancreasSponsors: Jonathan Hiatt, Michael Yeh, O. Joe Hines

- 129 -

JameS Lau, mDSpouse/Partner: PatriciaChildren: Jamie (13 yrs old)Caucus: Northern CaliforniaSpecialty: Gen Surgery (MIS/Bariatric/Trauma)Position/Location: Clinical Associate Professor of Surgery, Stanford University, Stanford, CaliforniaHobbies: Family, music, and filmSponsors: Tom Krummel, Mark Welton, David Spain

SHeLLey markS, mDCaucus: Northern CaliforniaSpecialty: General and Laparoscopic SurgeryPosition/Location: General Surgery Stall, Pala Alto Medical Foundation, Palo Alto, CaliforniaSponsors: Quan Duh, Lawrence Way, Lygia Stewart, Sherry Wren

Lea matSuoka, mDCaucus: Southern CaliforniaSpecialty: Hepatobiliary-Pancreatic Surgery and Abdominal TransplantPosition/Location: Assistant Professor of Clinical Surgery, Division of Hepatobiliary-Pancreatic Surgery and Abdominal Transplantation, Los Angeles, CaliforniaHobbies: Running, hiking, classic literature, automotive repairSponsors: Fred Weaver, Kenji Inaba, Edward Phillips

- 130 -

SuSan roWeLL, mDSpouse/Partner: Ron Barbosa, MDChildren: Adam (23), Tyler (17), Claire (11)Caucus: Oregon/HawaiiSpecialty: Trauma & Surgical Critical CarePosition/Location: Associate Professor, Department of Surgery, Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, Portland, OregonHobbies: Running, hiking, readingSponsors: Karen Deveney, Cliff Deveney, Jennifer Watters

barry SancHez, mDSpouse/Partner: KerriChildren: Tyler (21), Tessa (9), Lucas (6)Caucus: Southern CaliforniaSpecialty: General SurgeryPosition/Location: Director of Anacapa Surgical Associates, Director of Bariatric Surgery, Ventura County Medical Center, Ventura, CaliforniaHobbies: Music, sports, wine, running, guitar, coaching soccerSponsors: Ronald Latimer, Kenneth Waxman, Albert Wetter

robert SeLby, mDSpouse/Partner: DonnaChildren: Taylor (17), Bella (12), Cam (2)Caucus: Southern CaliforniaSpecialty: General SurgeryPosition/Location: Professor of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CaliforniaHobbies: Cycling, triathlons, rock climbingSurgical interests: Transfusion free surgery, surgery for neuroendocrine tumors, primary and metastatic liver tumors, peri-ampullary cancers, pancreatic cancers, bile duct injuries, cholangiocarcinomaSponsors: Fred Weaver, Glen Ault, Kenji Inaba

- 131 -

SHaWn Steen, mDSpouse/Partner: JennyChildren: Mason (4), Maverick (2)Caucus: Southern CaliforniaSpecialty: Surgical OncologyPosition/Location: Director of Surgical Oncology, Ventura County Medical Center, Ventura, CaliforniaHobbies: SurfingSurgical interests: Soft tissue and hepatobiliary surgerySponsors: Benjamin Paz, Armando Giuliano, Steven Colquhoun

Pierre tHeoDore, mDChildren: Renee (13) Christophe (15) Caucus: Northern CaliforniaSpecialty: Cardiothoracic SurgeryPosition/Location: Associate Professor of Clinical Surgery, School of Medicine, University of California, San FranciscoSurgical interests: Health information technology, global health, lung cancerSponsors: William Schecter, Arthur Hill, Hobart Harris

DanieL tSeng, mDSpouse/Partner: Pei-li Wang, MD Children: Ethan Tseng (10), Alex Tseng (8)Caucus: Oregon/HawaiiSpecialty: General SurgeryPosition/Location: Surgical Associates, PC specializing in GI and Minimally Invasive Surgery, Portland, OregonHobbies: Golf, tennis, skiing, hiking, wine tastingSponsors: John G. Hunter, Joseph Frankhouse, Blaine Standage

- 132 -

VaSSiLiki tSikitiS, mDSpouse/Partner: Steven EhlbeckChildren: Alexander, 14 monthsCaucus: Oregon/HawaiiSpecialty: Colon and Rectal SurgeryPosition/Location: Associate Professor, Department of Surgery, Oregon Health & Science University, Portland, OregonHobbies: Theater, travel, literature, languages, readingSponsors: John Vetto, Kim Lu, Karen Deveney

amanDa WHeeLer, mDSpouse/Partner: Andrew OgilvieCaucus: Northern CaliforniaSpecialty: Breast Surgical OncologyPosition/Location: Clinical Assistant Professor at Stanford University Medical CenterHobbies: Golf, tennis, yoga,Surgical interests: Patient education, patient decision makingSponsors: Sherry Wren, John Vetto, Tammy DeLaMelena

W. kent WiLLiamSon, mDCaucus: Oregon/HawaiiSpecialty: Vascular SurgeryPosition/Location: Chief, Division of Surgery, Providence St. Vincent Medical Center, Portland, OregonHobbies: Large format photography, cycling, fly fishing, backpackingSurgical interests: Complex aortic reconstruction and carotid diseaseSponsors: Clifford Deveney, Karen Deveney, Jim Peck

- 133 -

gorDan WiSbacH, mDSpouse/Partner: KristiChildren: Ryan (11), Kyle (9), Ella (7), Drew (4), Abby (2)Caucus: Southern CaliforniaSpecialty: General SurgeryPosition/Location: Vice Chairman, Department of Surgery, Naval Medical Center San Diego, San Diego, CaliforniaHobbies: Running, biking, swimming, skiing, reading, travel, astronomySponsors: Thomas Nelson, Sunil Boyrul, Michael Sise

karen Woo, mDCaucus: Southern CaliforniaSpecialty: Vascular SurgeryPosition/Location: Assistant Professor of Clinical Surgery, University of Southern California, Division of Vascular Surgery and Endovascular Therapy, Los Angeles, CAHobbies: Running, yoga, hiking, cooking, scubaSurgical interests: Comparative effectiveness research, health policy, dialysis accessSponsors: Fred Weaver, Ralph Dilley, Vincent Rowe

- 134 -

In MemoriamDeceased Members

William Fletcher, MD

Paul W. Johnston, MD

James V. Maloney, MD

Vincent A. Reger, MD

Thomas Russell, MD

- 135 -

In Memoriam

WiLLiam S. FLetcHer, mD1927-2014

William S. Fletcher was born in Arlington, MA, and grew up in Woodstock, VT. He attended Tilton Prep School in New Hampshire and then, wanting to become a surgeon, enlisted in the U.S. Navy in 1945 as a hospital corpsman. Following several years of duty, he matriculated to Dartmouth College, followed by Dartmouth and Harvard Medical Schools and he began his surgical internship and residency at Boston City Hospital. He then followed his mentor, J. Englebert Dunphy, to become chief resident at the University of Oregon Medical School, now OHSU, when Dr.

Dunphy accepted the position of chairman.

After completing residency, Dr. Dunphy asked Dr. Fletcher to stay as a member of the faculty and build a Division of Surgical Oncology. Dr. Fletcher made many pioneering advancements in the field of surgical oncology at OHSU. Dr. Fletcher was a disciple of Charles Huggins, M.D., one of the few surgeons to win the Nobel Prize for surgical endocrine ablations for hormone sensitive cancers. Appropriate selection of breast cancer patients who would respond to such operations improved dramatically with the development of testing of tumors for the presence of estrogen receptors. Dr. Fletcher established the first, and for many years, the only laboratory west of the Mississippi river capable of testing for estrogen receptors. He was one of the first surgeon investigators in organizations such as SWOG and NSABP, enrolling many patients in trials of surgery and adjuvant therapies to improve quality of life and survival of cancer patients and many of these pivotal studies form the foundation of modern multimodality cancer treatment.

Dr. Fletcher became chief of the Division of Surgical Oncology at OHSU in 1975, a position he held until his retirement in 2002. He was a member of the board of governors of the American College of Surgeons and U.S. Representative to the World Health Organization’s Melanoma Committee. He was author or co-author of more than 200 publications, President of the Portland Surgical Association, and President of the North Pacific Surgical Association in 1991. He was a member of more than 20

- 136 -

professional organizations. He built strong, enduring relationships with community organizations that have supported cancer research at OHSU, which continues to the present, with donations totaling nearly a half million dollars. He endowed OHSU with the William S. Fletcher Travel Award to permit surgery residents to present their cancer research at international oncology conferences.

In his spare time, he enjoyed hunting, raising and training Labrador retrievers, and spending time at with family and friends at his beach house in Pacific City, Oregon and his winter home in Maui. He is survived by his longtime partner, Charlene Davenport R.N, daughters Susan and Karen, son Bradford, and several grandchildren.

-Submitted by Rodney F. Pommier, MD

- 137 -

In Memoriam

PauL Warren JoHnSton, mD1923 - 2014

Paul Warren Johnston was born on January 27, 1923 in Kingsburg, CA to Karl Gunnar Johnston and Esther Matilda Youngberg Johnston, both Swedish immigrants.

Paul attended the University of Southern California, receiving his undergraduate degree in 1944, Phi Beta Kappa. He received his Doctor of Medicine in 1947. He was in the US Naval Reserve from 1947-9. He completed his Surgical Residency at the VA Hospital in Long Beach, CA in 1953.

After receiving his formal education and training, Paul joined a surgical practice with Drs. William Snyder Jr. and Edward M. Greaney, both Pacific Coast Surgical Association members. In 1957 he joined Dr. Arthur C Pattison, a past president of PCSA in the practice of general surgery. PW, as his friends called him, was elected to PCSA membership in 1967. I joined the group in 1969 and we practiced together until he retired in 2000.

He was the only pediatric surgeon in Pasadena for years. His pioneering work with ECHMO changed the landscape for children with hyaline membrane disease.

In addition to his surgical practice at Huntington Memorial Hospital in Pasadena, CA, he held positions as attending surgeon at USC-LAC Medical Center and consultant at Children’s Hospital Los Angeles. He was also an Associate Clinical Professor of Surgery at USC and Head of Service for General Surgical Residency at Huntington Memorial Hospital. He took great joy in teaching both colleagues and surgical residents training under him. His admonition was simple, “you are either learning what to do or what not to do. Be smart enough to know which is which.” He served as Chief of Staff in 1979 and served on many committees including Residency Review, Credentials, Surgical Audit, and the Institutional Review Board. He received the Children’s Hospital Los Angeles 25 Year Service Award in 1985. He was awarded the Best Teacher Award-Huntington Memorial Hospital Residents in 1986.

- 138 -

Paul had a great love for his family. He married Lillian Rogstad on November 25, 1949 in Pasadena. They had three children- Mark, Anne, and Gail. Many summers were spent vacationing as a family in the National Parks or at California beaches. There was even a special trip to Norway and Sweden where Paul and Lillian’s parents had come from. When grandchildren came along, many wonderful times were spent at Lake Almanor at the family cabin. Paul had a real sense of adventure and was always game to travel to a new place or try a new activity with his family.

Mark Johnston now lives with his wife Gay and daughter Christina in Coquitlam, British Columbia. He is a chaplain. Anne Fuller lives with her husband Rick in Spokane, WA. They have 3 grown children, Mikael, Daniel and Luke who remain in the Northwest. Anne is a cardiac nurse. Gail and her husband Roger live on Mercer Island. Their children Ryun and Khia live in the Seattle area. Gail is a family nurse practitioner.

Paul also had many hobbies. He was an avid reader of history. He loved to travel. In his retirement, he devoted more time to gardening of flowers and berries. He especially loved his woodworking hobby, gifting many of his family and friends with beautiful wood pens, kitchen implements, and bowls.

Paul was active in the Evangelical Covenant Church for many years. His faith in God was unwavering. In one of Paul’s final writings he penned, “What does God require of us?” The ancient prophet Micah stated it in this way: ‘do justice, love kindness, and walk humbly with your God.’

Truly a giant walked among us.

-Submitted by Donald J. Gaspard, MD

- 139 -

In Memoriam

JameS V. maLoney, Jr., mD1925-2014

A native of Rochester, New York, Jim Maloney completed undergraduate studies at the University of Pennsylvania in 1943, where he rowed crew. He received the MD degree from the University of Rochester, followed by internship at Johns Hopkins Surgical Hospital, a research fellowship in Physiology at the Harvard School of Public Health, and a residency in Surgery at Johns Hopkins University Hospital. From 1943-56, Jim was an active duty hospital corpsman and eventually a Lieutenant in the U.S. Naval Reserve.

Jim joined the UCLA Department of Surgery as Assistant Professor and founding Chief of the Thoracic Division on July 1, 1955. He rose through the professorial ranks and served from 1976-81 as the second Chair of the Department of Surgery. In 1979, he was named the Louis D. Beaumont Professor of Surgery, and in 1981 the Associate Dean for Extramural Programs. He became emeritus professor in 1991. He was known to all of us at UCLA as “JVM.”

Jim headed the team that introduced the era of open heart surgery to UCLA and the West Coast with the first successful open heart procedure west of the Mississippi River on February 24, 1956. Under his direction, the UCLA Cardiac Laboratory became one of the most active and productive research units in the School. Numerous fellows from all parts of the United States and many foreign countries started their careers in surgery by collaborating in research projects in this laboratory. Jim appointed Dr. Donald Mulder to the laboratory, and gave him the task of developing UCLA’s first pump oxygenator for open heart surgery. In February 1956, just seven months after the arrival of Drs. Maloney and Mulder, UCLA’s pump oxygenator was constructed, tested experimentally, and then proven successful clinically. The scope of cardiac surgery at UCLA changed as a result, and the division of Thoracic Surgery took a major step towards becoming the outstanding Cardiothoracic Surgery program it is today.

- 140 -

Jim became a member of PCSA in 1964, along with more than 25 scientific and professional organizations. He served as President of three of the most prestigious, including the Society of University Surgeons, the Society of Clinical Surgery, and the American Surgical Association. He was a member of the Board of Regents of the American College of Surgeons. As Chairman of the Surgical Education and Self-Assessment Program of the American College of Surgeons, Jim played an important role in the development of the highly successful SESAP modules, which have become international in scope. He was invited to present many named lectureships, including the John H. Gibbon Jr. Lecture of the American College of Surgeons.

Jim’s international awards include the Citation of Merit of the German Medical Association, presented on the 20th anniversary of the first open heart operation performed in Germany by him and Professor Linder at the Westend Krankenhaus in Berlin on December 15, 1958. He also received the Certificate of Appreciation from Ruperto Carolia University in Heidelberg, Germany, for contributions to German medicine and for fostering an Educational Exchange Program for surgeons, and Honorary Fellowship in the Association of Surgeons of Great Britain and Ireland.

Jim is remembered as a truly civic-minded colleague and as a caring and loving husband and father. On May 18, 1957, Jim married Patricia Carroll Keller. Their four children began to demonstrate similar traits of accomplishment so evident in Jim and Pat. Two children went to medical school, one was a Rhodes scholar, and all excelled academically. For recreation, Jim and his family loved to ski in the winter, fished and sailed in the summer, and often traveled to exotic places year-round.

Jim passed away on the morning of August 18, 2014. He is survived by Pat and his four children. He will be missed by all of us at UCLA, and his passing is a loss to American surgery.

-Submitted by Ronald W. Busuttil, MD, PhD

- 141 -

In Memoriam

Vincent reger, mD1956 - 2014

Vincent A. Reger died on Aug. 28, 2014 at his beloved beach house in Salisahan on the Oregon Coast. He was only 57 years old. Vince was born in Portland, Oregon to Donald and Patricia Reger.

He attended Woodrow Wilson High School and Lewis & Clark College in his hometown. He was admitted to OHSU School of Medicine after only three years of college. Vince was an intern at the University of Iowa Hospitals and then spent two years at the Naval Medical Center, Balboa Hospital in

San Diego. He completed his General Surgery residency at Virginia Mason Hospital in Seattle, the oldest approved surgical residency in the Pacific Northwest. Vince began his career as a community surgeon at the Portland Clinic with Roger Alberty. He was on the clinical teaching staff for the OHSU general surgery residents. In 1990, he opened his own private practice in general surgery at Providence St. Vincent Medical Center, a lifelong dream. During his 24 years at St. V, Vince served in many professional capacities, including Chief of Staff. He is survived by his parents and sister, Elizabeth (Liz).

As a child, he was unbeatable at the board game “Operation”. The object was to successfully remove whichever body part you were assigned during your turn, with a tweezer. If you touched either side, a buzzer would go off and the man’s nose would light up. Wikipedia defines the game as “game of physical skill” that “tests players’ hand-eye coordination and fine motor skills.” He was a pianist. As a pre-teen, he took apart a perfectly good radio because he wanted to know how it worked. Amazingly enough, he was able to put it back together, without any extra parts and it still worked. Vince was an Eagle Scout who was always fascinated with trains. He took many trips in North America with family and friends, especially his father.

As an adult, he took great pleasure in lake swimming, kayaking and rafting. Vince was admired and loved by everyone he came in contact with: his patients adored him, the residents were inspired by him, the Operating Room nurses wanted to work with him. The ICU and Recovery Room nurses never felt that they had “over-reacted” when they called Vince. He would

- 142 -

always come to the patient’s bedside. He was able, available, and affable. The nurses not only wanted to work with him, but when these RNs or their family or friends needed surgery, they wanted Vince to do it. Vince gave the OR team respect and kudos and always thanked them for supporting him during his operative procedures. His rafting/kayak trips down the Deschutes River with the nursing staff and friends were legendary. He would arrange every detail of these adventures.

Vince’s clinical research included his own invention of an early angioplasty devise to facilitate Endovascular Femoro-Popliteal bypass for which he was awarded a patent. Much of the basic research was done in Cambridge England facilitated by Professor Harold Ellis. As a consultant for Genentech, he did basic research on adhesion prevention.

Vince was always ahead of the curve with his forward thinking. One of the several start-up companies he founded was RMDI (Reger Medical Development Inc.), and another was EVI Endovascular Instruments. He presented at numerous medical conferences including in Australia and Europe. By 1999, he was using Electronic Medical Records and Voice Activation. For many of us struggling with EMR he was our go to physician. Dr. Reger was an exceptional combination of old school and avant-garde. He was approachable, always willing to answer questions and ready to use the newest technology when it was appropriate. He touched thousands of lives in a deeply personal, positive, and profound way - a truly brilliant clinician.

Vince never made a negative comment about anyone. Never, not once, did you hear destructive criticism or negativity. As Chief of Staff of Providence St. Vincent, he lifted people up with positive feedback and empowering words. He was always honest. We all saw him fired up at times. He was no push over. But even when he needed to be firm or express displeasure he did it in a way that was never demeaning or damaging to others. Any description of Vince included the words: compassionate, diligent, kind, courteous, excellent bedside manner, gifted, generous, gentle, brilliant, happy, and optimistic. He was the epitome of a warm caring physician, a thoughtful, intelligent, skilled surgeon. Vince was the definition of Professionalism. He always placed the patient’s interest above his own self-interest. There was the continuing pursuit of excellence and lifelong learning with the primacy of patient welfare.

- 143 -

He was elected a member of the Pacific Coast Surgical Association in 2004 and for the next ten years, he was a faithful participant in the Oregon & Hawaii caucus meeting and the Annual Meetings, especially in his treasured Hawaii.

Vince died after a 7-year battle with Mucoepidermoid Tracheal Carcinoma, a rare (0.2%) lung cancer. He underwent two tracheal resections and a full course of radiation. Two days prior to his death, he had just returned from the Mayo Clinic after being evaluated for Gene Therapy using Viral Vectors. Vince had sought second opinions in London, Germany and Spain. He was still working until two weeks before his death.

What I remember most about Vince was his incredible courage. There was never the slightest hint of depression, he was never down - always optimistic. Even as a patient, he was remarkable. When he died the entire office of his physician broke down in tears.

“If the words that you speak appeared on your skin, would you still be beautiful? “ For many of us there are days that we look tarnished, but Vince would always look like a Knight in Shining Armor. The words he spoke came straight from his heart, pure gold.

-Submitted by James Peck, MD

- 144 -

In Memoriam

tHomaS ruSSeLL, mD 1940 - 2014

Tom Russell was one of the finest men I have ever known and I was proud to be his friend. I first met Tom during his internship at SF General Hospital in the late sixties during his rotating internship at SFGH, but I did not really get to know him personally until he returned from two years in the Navy and started his surgical residency. At that time internship was independent of residency. So, at that time one had to compete for residency. I can remember being on the committee which selected residents for UCSF.

We must have had several hundred applicants each year once Dr. Dunphy took over the Chairmanship of Surgery at UC in 1964. I had my list of intern applicants from SFGH, among them was Tom. The applicants from UC’s straight internship usually were ranked at the top of the list, then those from the rotating internship at SFGH along with all outside applicants were in a second list. When I was pushing Tom’s application for the few remaining places in the UC Program, I remembered that he was a star tennis player and athletes always appealed to Dr. Dunphy. When I mentioned Tom’s expertise in tennis along with his other qualifications, Dr. Dunphy’s ears picked up and said “We’ve got to have that guy!”

Tom was born in San Francisco, received his college degree from UC Berkeley and his medical school degree from Creighton in Nebraska. My first memories of him were that he had a warm outgoing personality and always had a kind of military like bearing referring to me as “Sir”. At first I thought that it was some kind of affect, but I came to realize that Tom always showed special respect for his seniors, whether a senior resident or staff member. Moreover, that added to his sparkling personality resulted in his standing out in any crowd.

By the time Tom reached Chief Residency, I had come to know him very well. His honesty and integrity stood out. He was not reluctant to take responsibility for any errors of his and those of his underlings. These were few. I can only recall one special incident and it was that of the famous “clamp”, a very large hemostat that had been left in a patient’s abdomen after he had left the scene leaving a junior resident to close. Over the years

- 145 -

almost to the time of his death, he would recall the incident that he took as his responsibility. He remembered that he trembled in presenting the problem to me fearing he might be fired. How I laughed and said--”You know what to do! Get on with it!”

Tom, of course, remained a favorite of Dr. Dunphy. During resident outings, that always included tennis, Dunphy signed up Tom as his doubles partner and as far as I know they remained undefeated! Despite some sniggers from outsiders that no team dared to beat the professor, I can attest from personal experience that they truly were a dominant duo.

I had become so fond of him that during his Chief Residency I asked him if he would consider staying on as a member of my staff. He gave me a polite negative saying he wanted to do a super-specialty in colo-rectal surgery and had been accepted by the Gallagher group who functioned at Presbyterian and Children’s Hospitals. Needless to say, they recognized his outstanding merits and swept him up as a member of their group.

Carl Mathewson was Chief of Surgery at Presbyterian at that time and took Tom under his wing, passing on his job to Tom. I think Mathewson was glad to get rid of it because at that time, Presbyterian and Children had combined and this hospital complex was taking over two or three marginal hospitals and their staffs. This meant that a number of marginal surgeons had been swept up and given operating privileges.

Tom proved to be just the right person to deal with these issues. He had a very soft, polite way of dealing with problem surgeons. it involved making encouraging suggestions that they seek competent assistants or gave up doing operations that were beyond their capacity. He handled it so well and in such a nice way that as far as I know, no suits resulted and the hospital administrators and Tom’s fellow surgeons gave a sigh of relief.

Tom rapidly developed an outstanding practice, so much so that this combined with all his other duties kept him fully occupied, so much so that it must have distressed Nona, his wife. But when everyone recognizes how good you are, it is hard to avoid demands on your time and it is easy to get overwhelmed.

The American College of Surgeons was always looking for outstanding clinicians who have peer recognition. Tom was recruited to represent his area as a member of the Board of Regents of the American College of Surgeons. Surgeons can be a difficult group and within the Board there were many different opinions and hostile views. Tom’s personality was such

- 146 -

that he got along with all groups and he was so well respected that when a newly appointed Director clearly was not working out and was fired, Tom was nominated and appointed in his place. He was the first surgeon that did not come out of a fully academic environment so appointed.

Tom’s decade as Board Director clearly stood out. I am not competent to describe all his accomplishments that were so well documented by Carlos Pellegrino, at the June banquet for him just before his death. Carlos in his tribute said that “Tom transformed the College and helped, at a very difficult moment in its history, set up the foundation of what we have today to deal with the changes in health care funding, the disappearance of solo practice into group and institution practice. He brought us closer to many sister organizations and he reached out to all corners of this land with a message that elevated the stature of surgery and of all surgeons.”

Tom, during his tenure as Director, visited all the State Chapters of the College, attended meetings of the specialty societies and met and shook hands with more surgeons by far, than any other surgeon had ever done. He listened to complaints, most of which related to finances which he could do very little about, but assured the Societies members, that someone was listening. I have no question but that when he finished his tour as Director, he was the best known and most highly respected surgeon in the entire United States.

His leadership reminded me of an ancient politician, named Jim Farley, who was Franklin Roosevelt’s political advisor and Chief of Staff. Farley allegedly shook hands with every major politician in the United States and moreover, remembered everyone’s name! That was Tom. He enjoyed people and they enjoyed him. He and I in recent years attended meetings together, and I often had to wait for him at the exit of the meeting while he made sure that he greeted everyone. I accused Tom of never leaving a meeting until he had personally addressed and shaken hands with everyone in the room!

I shall miss him greatly. I followed his outstanding medical career as proud as any parent might. We became fast personal friends after his retirement as Director of the College as we shared the same political views, enjoyed one another’s company and exchanged bragging rights about our families. I have lost an irreplaceable friend.

He leaves behind his loving wife Nona, herself a pathologist, and two daughters, of whom he was very proud-- Katie, in her final year of surgical residency in Utah, and Jackie, training to be a vetinarian at UC Davis

-Submitted by F. William Blaisdell, MD

- 147 -

Future meetings

2016 February 13- 16, 2016 HOST: Oregon/Hawaii SITE: Fairmont Orchid, Kohala Coast, HI

2017 February 17- 20, 2017 HOST: Southern California SITE: Hyatt Regency Indian Wells Resort & Spa, Indian Wells, CA

Pacific Coast Surgical Association

Pacific Coast Surgical Associationc/o ACS Association Management Services

633 N. St. Clair StreetChicago, IL 60611-3211

PHONE: 800-274-9083FAX: 312-278-0793

EMAIL: pcsa@facs.orgWEB: www.pcsaonline.org